1
00:00:00 --> 00:00:01
2
00:00:01 --> 00:00:04
The following content is
provided by MIT OpenCourseWare
3
00:00:03 --> 00:00:06
under a Creative
Commons license.
4
00:00:06 --> 00:00:08
Additional information
about our license and MIT
5
00:00:08 --> 00:00:14
OpenCourseWare in general is
available at ocw.mit.edu.
6
00:00:14 --> 00:00:18
PROFESSOR: I have what I think
of as a couple of fascinating
7
00:00:18 --> 00:00:26
questions that I will use to
occupy us for the next --
8
00:00:26 --> 00:00:31
for the last couple of
lectures of the course.
9
00:00:31 --> 00:00:35
In the context of talking about
sleeping and dreams, I
10
00:00:35 --> 00:00:40
mentioned that the hunger drive
is strong, but it's not so
11
00:00:40 --> 00:00:46
strong that if you wanted to,
you couldn't starve
12
00:00:46 --> 00:00:48
yourself to death.
13
00:00:48 --> 00:00:53
But an interesting question
would be why an otherwise
14
00:00:53 --> 00:00:58
healthy adolescent
girl would do that.
15
00:00:58 --> 00:01:05
And why in doing that she would
argue vociferously that there
16
00:01:05 --> 00:01:08
was nothing wrong with her and
that she wasn't hungry even
17
00:01:08 --> 00:01:14
while starving herself
potentially to death.
18
00:01:14 --> 00:01:15
That's one question.
19
00:01:15 --> 00:01:19
That will occupy
probably today.
20
00:01:19 --> 00:01:21
You'll see that I did handouts
for both this lecture and the
21
00:01:21 --> 00:01:24
next lecture rolled together in
case I get to the
22
00:01:24 --> 00:01:26
next one today.
23
00:01:26 --> 00:01:34
The second question is -- well,
you might have found the
24
00:01:34 --> 00:01:41
evolutionary psych argument
about asymmetries between the
25
00:01:41 --> 00:01:45
sexes in terms of what they
want in relationships to
26
00:01:45 --> 00:01:46
be reasonably compelling.
27
00:01:46 --> 00:01:52
That argument about guys
wanting to -- everybody wanting
28
00:01:52 --> 00:01:55
to propagate their genes, but
because women get pregnant and
29
00:01:55 --> 00:01:59
are thus tied up with the baby
for an extended period of time,
30
00:01:59 --> 00:02:02
that you end up with an
asymmetry that would cause
31
00:02:02 --> 00:02:07
males to want more sex,
more often, with more
32
00:02:07 --> 00:02:10
partners, than women.
33
00:02:10 --> 00:02:13
You might have found that
appealing, at least as an
34
00:02:13 --> 00:02:17
intellectual construct.
35
00:02:17 --> 00:02:20
But how would we explain, would
that explain, how might it
36
00:02:20 --> 00:02:27
explain why at least some males
end up engaging in coercive
37
00:02:27 --> 00:02:30
sexual behavior, sexual
behavior that does not
38
00:02:30 --> 00:02:34
appear to be consensual
between the partners?
39
00:02:34 --> 00:02:37
And that's what's going to
occupy us for the last
40
00:02:37 --> 00:02:39
lecture of the course.
41
00:02:39 --> 00:02:44
Now these are very different
problems, the problem of eating
42
00:02:44 --> 00:02:49
disorders on the one hand and
coercive sexual behavior, or
43
00:02:49 --> 00:02:53
more colloquially, date
rape on the other side.
44
00:02:53 --> 00:02:56
But they do have some
interesting parallels,
45
00:02:56 --> 00:02:58
one with the other.
46
00:02:58 --> 00:03:02
These are outlined a bit,
I guess, in the abstract
47
00:03:02 --> 00:03:05
part of the handout.
48
00:03:05 --> 00:03:11
They're both problems that
are gender specific.
49
00:03:11 --> 00:03:15
The overwhelming number of
eating disorder patients are
50
00:03:15 --> 00:03:22
female, and the overwhelming
number of people who get into
51
00:03:22 --> 00:03:27
trouble for, you know, brought
up on charges in coercive
52
00:03:27 --> 00:03:31
sexual behavior cases,
for instance, are male.
53
00:03:31 --> 00:03:34
So they're gender specific.
54
00:03:34 --> 00:03:35
That's of some interest.
55
00:03:35 --> 00:03:38
56
00:03:38 --> 00:03:41
They both serve a useful
function at the end of the
57
00:03:41 --> 00:03:47
course, because they're both
useful for bringing back theme
58
00:03:47 --> 00:03:52
after theme that we've seen
throughout the course, themes
59
00:03:52 --> 00:03:58
like revisiting is it
nature, is it nurture?
60
00:03:58 --> 00:04:02
Is it biology or
is it sociology?
61
00:04:02 --> 00:04:06
And the answer always turns
out to be, or often turns
62
00:04:06 --> 00:04:10
out to be, that these are
complicated interactions.
63
00:04:10 --> 00:04:14
And the problems of eating
disorders and coercive sex turn
64
00:04:14 --> 00:04:19
out to be particularly rich
interactions between
65
00:04:19 --> 00:04:23
a number of factors.
66
00:04:23 --> 00:04:29
And by the same token, neither
of them is well dealt with in
67
00:04:29 --> 00:04:33
any simpleminded, oh, give them
a pill, for instance,
68
00:04:33 --> 00:04:35
kind of way.
69
00:04:35 --> 00:04:39
And they're both what could
be described as being
70
00:04:39 --> 00:04:41
successful disasters.
71
00:04:41 --> 00:04:43
I'll elaborate on that later.
72
00:04:43 --> 00:04:48
But both of them are in a
perverse sense successful
73
00:04:48 --> 00:04:54
behaviors and in a more obvious
sense disasters, unsuccessful.
74
00:04:54 --> 00:04:58
75
00:04:58 --> 00:05:05
Let me start by sketching a
portrait of what would be a
76
00:05:05 --> 00:05:11
typical patient with the
diagnosis of anorexia nervosa.
77
00:05:11 --> 00:05:13
The term simply means
-- anorexia means a
78
00:05:13 --> 00:05:14
lack of appetite.
79
00:05:14 --> 00:05:19
Nervosa is just what
you stick on when it's
80
00:05:19 --> 00:05:21
of nervous origins.
81
00:05:21 --> 00:05:25
You know, you could have
called it psychogenic
82
00:05:25 --> 00:05:28
or something like that.
83
00:05:28 --> 00:05:30
It just means a loss of
appetite that you're not
84
00:05:30 --> 00:05:34
going to explain by
some organic cause.
85
00:05:34 --> 00:05:38
A typical patient would be an
adolescent girl, say fourteen,
86
00:05:38 --> 00:05:43
fifteen, sixteen, who gets
brought typically by her
87
00:05:43 --> 00:05:46
family to the doctor.
88
00:05:46 --> 00:05:48
Very skinny.
89
00:05:48 --> 00:05:51
Part of the characteristics you
can see on the clinical
90
00:05:51 --> 00:05:56
criteria for the diagnosis --
part of the characteristic is a
91
00:05:56 --> 00:05:59
refusal to maintain what's
considered a normal
92
00:05:59 --> 00:06:00
body weight.
93
00:06:00 --> 00:06:03
So maybe, you know, at her
height and age, she should
94
00:06:03 --> 00:06:04
weigh about a hundred pounds.
95
00:06:04 --> 00:06:08
She might come in weighing
seventy-five pounds looking to
96
00:06:08 --> 00:06:14
all the world like she is
emaciated -- looking to all the
97
00:06:14 --> 00:06:16
world but one like
she's emaciated.
98
00:06:16 --> 00:06:22
One of the characteristics is a
-- well, I think it's on the
99
00:06:22 --> 00:06:25
handout -- distortion of
body image, a denial that
100
00:06:25 --> 00:06:26
you're actually skinny.
101
00:06:26 --> 00:06:33
And it's not just, you know,
some sort of a cranky, you
102
00:06:33 --> 00:06:38
know, what did you get
in biology this term?
103
00:06:38 --> 00:06:40
Did you flunk
biology this term?
104
00:06:40 --> 00:06:43
No, I didn't flunk biology this
term When you can see on the
105
00:06:43 --> 00:06:45
report card that it says F
or something like that.
106
00:06:45 --> 00:06:47
It's not that kind of denial.
107
00:06:47 --> 00:06:54
It's almost like a perceptual
disorder, where a young girl
108
00:06:54 --> 00:07:00
who looks to everybody else
like she is a famine victim
109
00:07:00 --> 00:07:05
looks at herself in the
mirror and says, I look fat.
110
00:07:05 --> 00:07:08
As though she was seeing
something that literally
111
00:07:08 --> 00:07:10
wasn't there.
112
00:07:10 --> 00:07:14
This is combined with an
intense fear of being fat,
113
00:07:14 --> 00:07:18
of being overweight.
114
00:07:18 --> 00:07:21
And one of the official
diagnostic criterion is a
115
00:07:21 --> 00:07:25
cessation of menstrual cycles
for more than three months.
116
00:07:25 --> 00:07:28
There was an interesting
article -- Bo, you
117
00:07:28 --> 00:07:29
sent it around, right?
118
00:07:29 --> 00:07:34
Did you send around the New
York Times thing about EDNOS?
119
00:07:34 --> 00:07:36
An interesting article in the
New York Times science section
120
00:07:36 --> 00:07:39
last week pointing out
one of the problems in
121
00:07:39 --> 00:07:41
psychiatric diagnosis.
122
00:07:41 --> 00:07:42
Suppose you got a patient.
123
00:07:42 --> 00:07:46
She's fifteen years old,
skinny as a rail, intense
124
00:07:46 --> 00:07:50
fear of being fat.
125
00:07:50 --> 00:07:52
Says she looks fat.
126
00:07:52 --> 00:07:56
And her monthly cycles are
irregular, but they've
127
00:07:56 --> 00:07:58
never disappeared for
a full three months.
128
00:07:58 --> 00:08:01
Under the official rules of the
game, you can't give her a
129
00:08:01 --> 00:08:05
diagnosis of anorexia because
she doesn't meet all the
130
00:08:05 --> 00:08:06
diagnostic criteria.
131
00:08:06 --> 00:08:08
Clearly has an eating disorder.
132
00:08:08 --> 00:08:13
What you end up labeling
her as is eating disorder
133
00:08:13 --> 00:08:14
not otherwise specified.
134
00:08:14 --> 00:08:19
EDNOS is the official
category for this.
135
00:08:19 --> 00:08:25
It becomes an issue in the
economics of health care
136
00:08:25 --> 00:08:27
because what you can get
reimbursed for, what you can
137
00:08:27 --> 00:08:31
treat for, are real diseases.
138
00:08:31 --> 00:08:35
I mean, reasonably enough, you
can't go to your doctor and
139
00:08:35 --> 00:08:41
say, you know, I want a pile of
drugs and therapy that I want
140
00:08:41 --> 00:08:49
somebody else to pay for
because I hate my calculus
141
00:08:49 --> 00:08:52
TA pathologically.
142
00:08:52 --> 00:08:54
143
00:08:54 --> 00:08:57
Yeah, OK.
144
00:08:57 --> 00:09:00
You can't just decide that --
well, you can just decide that
145
00:09:00 --> 00:09:01
you're ill in something.
146
00:09:01 --> 00:09:04
Or you can't just walk
in and say, you know, I
147
00:09:04 --> 00:09:07
want you to treat me.
148
00:09:07 --> 00:09:11
I desperately need you to
change the shape of my nose,
149
00:09:11 --> 00:09:15
and I'm not thrilled with my
rear end and, you know, I kind
150
00:09:15 --> 00:09:18
of want you to reshape my whole
body because, you know, my
151
00:09:18 --> 00:09:21
body, it's just not right.
152
00:09:21 --> 00:09:24
You have to get a diagnosis of,
you know, body dysmorphic
153
00:09:24 --> 00:09:26
disorder or something like that
before you can persuade the
154
00:09:26 --> 00:09:27
third party payers to do it.
155
00:09:27 --> 00:09:31
Anyway, in psychiatric land
this is a big problem because
156
00:09:31 --> 00:09:35
it's very difficult to come up
with -- you know, there's
157
00:09:35 --> 00:09:37
no blood test, right?
158
00:09:37 --> 00:09:40
If you've got polio,
there's a polio virus
159
00:09:40 --> 00:09:41
somewhere to look for.
160
00:09:41 --> 00:09:44
If you've got an eating
disorder there's not.
161
00:09:44 --> 00:09:48
And so exactly how to
label people is a
162
00:09:48 --> 00:09:49
substantial problem.
163
00:09:49 --> 00:09:51
But I'm not going to
say more about it.
164
00:09:51 --> 00:09:59
In any case, so
here's a patient.
165
00:09:59 --> 00:10:03
This disorder is interesting
as an interplay of mind and
166
00:10:03 --> 00:10:06
body in many, many ways.
167
00:10:06 --> 00:10:10
Part of the reason that it's
interesting is because there
168
00:10:10 --> 00:10:16
are all sorts of psychiatric
consequences that just arise
169
00:10:16 --> 00:10:21
from the fact that this girl --
I'll stick with it being a
170
00:10:21 --> 00:10:24
female patient because anorexia
is about eight to one, nine
171
00:10:24 --> 00:10:28
to one female -- because
she's starving herself.
172
00:10:28 --> 00:10:33
For instance, starving
yourself is depressing.
173
00:10:33 --> 00:10:37
If you are really hungry, you
also tend to have more symptoms
174
00:10:37 --> 00:10:38
of clinical depression.
175
00:10:38 --> 00:10:42
Is depression part of the
eating disorder pattern?
176
00:10:42 --> 00:10:44
177
00:10:44 --> 00:10:48
Is it part of the pathology
or is it a side effect
178
00:10:48 --> 00:10:50
of the pathology?
179
00:10:50 --> 00:10:55
In any case, it is not
an uncommon disorder.
180
00:10:55 --> 00:10:58
Point prevalence is jargon for
saying if I go and look at a
181
00:10:58 --> 00:11:03
population at this point in
time, how many people have the
182
00:11:03 --> 00:11:04
disorder I'm looking for?
183
00:11:04 --> 00:11:07
And if you look at a population
of young women, the point
184
00:11:07 --> 00:11:11
prevalence of anorexia is
about half of a percent.
185
00:11:11 --> 00:11:15
If you broaden it to this
EDNOS, eating disorder not
186
00:11:15 --> 00:11:18
otherwise specified category,
that can go up to anywhere
187
00:11:18 --> 00:11:23
between 2% and 5% depending
on what you read.
188
00:11:23 --> 00:11:25
If you look at prevalence
rates, as I say, they're about
189
00:11:25 --> 00:11:29
eight to one female to male.
190
00:11:29 --> 00:11:33
So it's a very heavily
female disorder.
191
00:11:33 --> 00:11:36
192
00:11:36 --> 00:11:41
And it's a dangerous disorder.
193
00:11:41 --> 00:11:46
For patients with full-blown
anorexia diagnosis, the
194
00:11:46 --> 00:11:49
mortality rate can be
as high as about 5%.
195
00:11:49 --> 00:11:53
That's very high for a disorder
of a population that's
196
00:11:53 --> 00:11:57
otherwise, you know,
young healthy women.
197
00:11:57 --> 00:12:04
What kills you, by the way, is
not starving to death, but
198
00:12:04 --> 00:12:05
things like heart attack.
199
00:12:05 --> 00:12:09
200
00:12:09 --> 00:12:12
Your electrolytes get to be
so out of balance that your
201
00:12:12 --> 00:12:15
heart fails to work and
things of that sort.
202
00:12:15 --> 00:12:20
It is also a disorder, in a
sense like multiple personality
203
00:12:20 --> 00:12:26
disorder, that has changed
greatly in its frequency in the
204
00:12:26 --> 00:12:32
population in historical time,
like the last forty years.
205
00:12:32 --> 00:12:35
It's different from multiple
personality disorder in that
206
00:12:35 --> 00:12:38
this change may be a real
change in incidence.
207
00:12:38 --> 00:12:40
Remember the argument was that
in multiple personality
208
00:12:40 --> 00:12:47
disorder, dissociative disorder
had been there all along, and
209
00:12:47 --> 00:12:51
that multiple personality was
merely the way that it manifest
210
00:12:51 --> 00:12:57
itself, that the dissociative
disorder manifested itself in
211
00:12:57 --> 00:13:01
modern Western culture.
212
00:13:01 --> 00:13:04
In the case of eating
disorders, it really may be
213
00:13:04 --> 00:13:10
that the disorder is itself
more frequent than it's
214
00:13:10 --> 00:13:12
been in the past.
215
00:13:12 --> 00:13:20
It is certainly a -- depends
on what society you are in.
216
00:13:20 --> 00:13:25
It was characteristically, even
as recently as probably twenty
217
00:13:25 --> 00:13:28
years ago, it was absolutely
characteristically a disease
218
00:13:28 --> 00:13:32
of middle-class white girls.
219
00:13:32 --> 00:13:39
It has since managed to embrace
diversity and reach out
220
00:13:39 --> 00:13:42
to other groups in
Western culture.
221
00:13:42 --> 00:13:46
For instance, virtually unknown
in Japan until fairly recently,
222
00:13:46 --> 00:13:49
but now is a disorder
showing up in Japan.
223
00:13:49 --> 00:13:53
I think I just read something
that even more recently, it's
224
00:13:53 --> 00:13:57
now starting to show up in
mainland China, where
225
00:13:57 --> 00:13:58
it was unknown.
226
00:13:58 --> 00:14:01
One of the requirements for a
good eating disorder
227
00:14:01 --> 00:14:03
population, by the way, is a
culture where there's
228
00:14:03 --> 00:14:04
lots of food.
229
00:14:04 --> 00:14:07
You don't have people
with eating disorders
230
00:14:07 --> 00:14:12
of this sort in famine.
231
00:14:12 --> 00:14:16
You can be seventy-five pounds
when you're supposed to be a
232
00:14:16 --> 00:14:18
hundred pounds because there
isn't enough food, but it's not
233
00:14:18 --> 00:14:23
because you're refusing to
maintain your body weight.
234
00:14:23 --> 00:14:29
So it is a disorder of a
society that is feeding
235
00:14:29 --> 00:14:35
everybody, that would be able
to feed everybody successfully.
236
00:14:35 --> 00:14:38
So where does this come from?
237
00:14:38 --> 00:14:39
What's it's etiology?
238
00:14:39 --> 00:14:42
What are the risk factors
that contribute here?
239
00:14:42 --> 00:14:45
240
00:14:45 --> 00:14:48
I can tell it must be
time to flip pages on
241
00:14:48 --> 00:14:50
the handout, right?
242
00:14:50 --> 00:14:50
Look at that.
243
00:14:50 --> 00:14:52
What's the causes?
244
00:14:52 --> 00:14:59
And it reminds me to
caution, to step back for
245
00:14:59 --> 00:15:00
a couple of cautions.
246
00:15:00 --> 00:15:06
The primary caution here is
that this is not intended to be
247
00:15:06 --> 00:15:11
talking about you specifically.
248
00:15:11 --> 00:15:13
Because, well, all right,
here, let's jump ahead.
249
00:15:13 --> 00:15:19
We can say stuff about,
again typically, the
250
00:15:19 --> 00:15:21
girl who is a patient.
251
00:15:21 --> 00:15:24
There are characteristics
that -- not every -- you
252
00:15:24 --> 00:15:27
know, it's a big, wide
distribution as usual.
253
00:15:27 --> 00:15:31
But we can say something about
where the sort of typical
254
00:15:31 --> 00:15:32
patient might lie.
255
00:15:32 --> 00:15:39
Typically she is adolescent --
sometime after the onset of
256
00:15:39 --> 00:15:43
puberty is the, sort of, risk
period for the onset of
257
00:15:43 --> 00:15:49
anorexia typically -- described
as a good girl, something of a
258
00:15:49 --> 00:15:52
perfectionist, the one who
never gave any trouble.
259
00:15:52 --> 00:15:54
And now you should be
immediately able to see why I
260
00:15:54 --> 00:15:57
put this caution in that I'm
not talking about you.
261
00:15:57 --> 00:16:01
Who in the world gets
to MIT by being a bad,
262
00:16:01 --> 00:16:03
evil, non-perfectionist?
263
00:16:03 --> 00:16:05
Well, you know, there's a
couple of you here maybe who,
264
00:16:05 --> 00:16:07
you know, just got through
because you're brilliant, bad,
265
00:16:07 --> 00:16:09
evil, non-perfectionists
or something like that.
266
00:16:09 --> 00:16:17
But the rest of you spent those
adolescent years being -- those
267
00:16:17 --> 00:16:18
of you who were women -- the
rest of you didn't spend
268
00:16:18 --> 00:16:19
your time being women.
269
00:16:19 --> 00:16:24
But, you know, you spent your
time being good and doing your
270
00:16:24 --> 00:16:27
homework and not raising a lot
of trouble and stuff like that.
271
00:16:27 --> 00:16:27
Oh, great.
272
00:16:27 --> 00:16:30
Now let's talk about
the family a bit.
273
00:16:30 --> 00:16:34
It's an interesting disorder
because it turns out to be
274
00:16:34 --> 00:16:35
important to talk
about the family.
275
00:16:35 --> 00:16:42
If you are dealing with a lot
of other health issues, your
276
00:16:42 --> 00:16:45
family background is of some
interest, particularly for sort
277
00:16:45 --> 00:16:49
of genetic reasons, but the
structure of your family
278
00:16:49 --> 00:16:52
is typically not
desperately important.
279
00:16:52 --> 00:16:54
Here it may really
be important.
280
00:16:54 --> 00:16:57
The family -- again, wide range
possible -- but the typical
281
00:16:57 --> 00:17:02
family would be one that's
described as -- what have I got
282
00:17:02 --> 00:17:06
here? -- overprotective
and also perfectionist,
283
00:17:06 --> 00:17:07
achievement oriented.
284
00:17:07 --> 00:17:09
And you're sitting there
saying, oh my god, not only was
285
00:17:09 --> 00:17:13
I good, but my family, they're
overprotective, and they're
286
00:17:13 --> 00:17:15
achievement oriented.
287
00:17:15 --> 00:17:18
And when I said that what I
really wanted to do was go to
288
00:17:18 --> 00:17:21
the community college, they
locked me in my room for three
289
00:17:21 --> 00:17:24
days until I finished the
MIT application and stuff.
290
00:17:24 --> 00:17:28
You know, this is our history.
291
00:17:28 --> 00:17:29
These are our people.
292
00:17:29 --> 00:17:31
We know them.
293
00:17:31 --> 00:17:34
The other characteristic, to
introduce a little piece of
294
00:17:34 --> 00:17:40
jargon here, the families
are described as enmeshed.
295
00:17:40 --> 00:17:45
This is a piece of jargon that
I understand well, because I
296
00:17:45 --> 00:17:50
come from a family that is
beautifully described, you
297
00:17:50 --> 00:17:52
know, beautifully fits
the enmeshed idea.
298
00:17:52 --> 00:17:56
I don't understand how my
sisters got through their,
299
00:17:56 --> 00:17:59
you know, youth without
an eating disorder.
300
00:17:59 --> 00:18:02
Because every year when I talk
about this, if I talk about the
301
00:18:02 --> 00:18:06
risk factors, you know, it just
sounds like my family, our nice
302
00:18:06 --> 00:18:09
achievement-oriented
enmeshed family.
303
00:18:09 --> 00:18:14
Enmeshed means a family where
people -- imagine a family,
304
00:18:14 --> 00:18:17
like yours maybe, where people
finish each other's sentences
305
00:18:17 --> 00:18:19
and stuff like that.
306
00:18:19 --> 00:18:25
They're sort of all over
each other psychologically.
307
00:18:25 --> 00:18:27
You know what they want.
308
00:18:27 --> 00:18:30
They know what you want.
309
00:18:30 --> 00:18:37
The place to see it in the
Wolfe family, as my wife who of
310
00:18:37 --> 00:18:41
course married into this found
out, is go out to
311
00:18:41 --> 00:18:43
dinner with them.
312
00:18:43 --> 00:18:46
You don't want to do this,
because it's pathological.
313
00:18:46 --> 00:18:48
First you've got to decide
where to go for dinner, right?
314
00:18:48 --> 00:18:50
So everybody gets together.
315
00:18:50 --> 00:18:52
You decide where
to go to dinner.
316
00:18:52 --> 00:18:53
You've almost got a consensus.
317
00:18:53 --> 00:18:57
You're going to go to Legal
Sea Foods or something.
318
00:18:57 --> 00:19:01
At which point one of us, it
might well be me, points out
319
00:19:01 --> 00:19:03
my mother doesn't
really like fish.
320
00:19:03 --> 00:19:05
Is my mother fussing
about this?
321
00:19:05 --> 00:19:07
No, my mother's perfectly
happy to go along with
322
00:19:07 --> 00:19:09
what everybody else wants.
323
00:19:09 --> 00:19:13
But, you know, I'll
say, you know, but Mom
324
00:19:13 --> 00:19:14
doesn't like fish.
325
00:19:14 --> 00:19:16
Well, actually, these days
I would say, but Gaga
326
00:19:16 --> 00:19:18
doesn't like fish.
327
00:19:18 --> 00:19:23
My eldest child when he was a
toddler named my mother Gaga.
328
00:19:23 --> 00:19:27
And that's been her name
ever since, which is, you
329
00:19:27 --> 00:19:29
know, she deals with it.
330
00:19:29 --> 00:19:34
Anyway, so all right, we've
got to cancel that one.
331
00:19:34 --> 00:19:37
So now the whole
conversation starts again.
332
00:19:37 --> 00:19:39
And you can do this for hours.
333
00:19:39 --> 00:19:42
334
00:19:42 --> 00:19:45
Julie, my spouse, learned the
best thing to do, particularly
335
00:19:45 --> 00:19:48
if we're out somewhere, you're
wandering around trying to
336
00:19:48 --> 00:19:51
decide where to go to a
restaurant, is just drop
337
00:19:51 --> 00:19:52
about five, six paces back.
338
00:19:52 --> 00:19:55
You just don't want to be
in this conversation.
339
00:19:55 --> 00:19:59
But eventually we'll end up at
a restaurant, at which point
340
00:19:59 --> 00:20:04
everybody's ordering for
everybody else and is ordering
341
00:20:04 --> 00:20:08
stuff that they don't
necessarily want to eat, but
342
00:20:08 --> 00:20:09
they think somebody else
might want to eat.
343
00:20:09 --> 00:20:11
My mother is the queen of this.
344
00:20:11 --> 00:20:14
My mother will order things she
doesn't even like because she
345
00:20:14 --> 00:20:17
thinks one of her children
wants to try it or
346
00:20:17 --> 00:20:18
something like that.
347
00:20:18 --> 00:20:20
And this is still true now
that her children are
348
00:20:20 --> 00:20:23
in their late forties.
349
00:20:23 --> 00:20:26
It's OK, Ma.
350
00:20:26 --> 00:20:28
I'm not starving anymore.
351
00:20:28 --> 00:20:30
Anyway, that's enmeshed.
352
00:20:30 --> 00:20:33
353
00:20:33 --> 00:20:39
These families are also
characteristically intolerant
354
00:20:39 --> 00:20:44
of expressions of
conflict and anger.
355
00:20:44 --> 00:20:48
It's not that there aren't
conflicts in these settings,
356
00:20:48 --> 00:20:52
but the family will act as
a unit to smooth them out.
357
00:20:52 --> 00:20:59
This is not a, you know,
dramatic family where people
358
00:20:59 --> 00:21:04
throw crockery at each other
and then, you know, in act
359
00:21:04 --> 00:21:06
five they all hug or
something like that.
360
00:21:06 --> 00:21:12
This is a family where if
there's an issue, it's dealt
361
00:21:12 --> 00:21:16
with in some quiet, perhaps
even subterranean,
362
00:21:16 --> 00:21:18
kind of a way.
363
00:21:18 --> 00:21:21
364
00:21:21 --> 00:21:28
So that's sort of the
patient and the family.
365
00:21:28 --> 00:21:34
And then you've got to ask,
given a disorder that has been
366
00:21:34 --> 00:21:39
a disorder of Western
middle-class culture, you've
367
00:21:39 --> 00:21:43
got to ask what it is about the
culture that might be
368
00:21:43 --> 00:21:45
contributory here.
369
00:21:45 --> 00:21:55
Again, there are other
situations in which the broader
370
00:21:55 --> 00:22:00
environment is important, like
is it putting stress on you in
371
00:22:00 --> 00:22:01
some sort of global
kind of a way.
372
00:22:01 --> 00:22:04
But here the specific demands
of the culture turn out to
373
00:22:04 --> 00:22:06
be of particular interest.
374
00:22:06 --> 00:22:15
And the particular demand that
people focus on is the degree
375
00:22:15 --> 00:22:21
to which American culture, more
broadly Western culture, is
376
00:22:21 --> 00:22:26
simultaneously obsessed with
both food and thinness.
377
00:22:26 --> 00:22:29
This is a difficult
combination, right?
378
00:22:29 --> 00:22:34
So how do we know that this
is a culture obsessed
379
00:22:34 --> 00:22:35
with thinness?
380
00:22:35 --> 00:22:41
One of the most telling ways
is to take a look at the
381
00:22:41 --> 00:22:43
ideals of female beauty.
382
00:22:43 --> 00:22:49
What is it that society as
a whole declares to be
383
00:22:49 --> 00:22:54
beautiful in women?
384
00:22:54 --> 00:23:01
And if you do something --
I should check if there's
385
00:23:01 --> 00:23:03
a cool website for this.
386
00:23:03 --> 00:23:06
If you just line up the
pictures of Miss America, for
387
00:23:06 --> 00:23:12
instance, over the last fifty,
sixty years -- if you take a
388
00:23:12 --> 00:23:17
look at Miss America from the
1940s, you would agree that
389
00:23:17 --> 00:23:20
she's a perfectly
attractive-looking woman, but
390
00:23:20 --> 00:23:24
you'd think she looks
a little chunky.
391
00:23:24 --> 00:23:31
There's a lot more on her than
would be the case for a modern
392
00:23:31 --> 00:23:37
Miss America or a modern --
open up a fashion magazine at
393
00:23:37 --> 00:23:40
random and look at the models.
394
00:23:40 --> 00:23:45
Much skinner than the ideal
would have been a couple
395
00:23:45 --> 00:23:46
of generations ago.
396
00:23:46 --> 00:23:54
Or take a look at one that I
learned about when my children
397
00:23:54 --> 00:23:57
became big fans of the
James Bond movies.
398
00:23:57 --> 00:24:02
So in every James Bond movie,
there's the girl, right.
399
00:24:02 --> 00:24:05
She's been getting a lot
skinnier over the years.
400
00:24:05 --> 00:24:08
If you go back to the early
ones -- I don't know how
401
00:24:08 --> 00:24:10
many of you are great
James Bond aficionados.
402
00:24:10 --> 00:24:15
But if you go back and look at
a movie like Goldfinger -- I
403
00:24:15 --> 00:24:18
will not recite all the names
of the characters because
404
00:24:18 --> 00:24:23
they're all bad lewd puns I'm
realizing as I'm thinking about
405
00:24:23 --> 00:24:31
this -- but if you go back and
look at the girl in Goldfinger
406
00:24:31 --> 00:24:34
or in Dr. No or something like
that, you will find again --
407
00:24:34 --> 00:24:38
that's from the early '60s, mid
'60s -- you'll find that she
408
00:24:38 --> 00:24:40
looks, you know, perfectly
attractive woman.
409
00:24:40 --> 00:24:45
But again, there's more of her
than there would be in -- who's
410
00:24:45 --> 00:24:48
the tart in the most recent --
411
00:24:48 --> 00:24:49
AUDIENCE: Halle Berry.
412
00:24:49 --> 00:24:50
PROFESSOR: Halle Berry.
413
00:24:50 --> 00:24:50
Yes.
414
00:24:50 --> 00:24:51
Nothing there, right.
415
00:24:51 --> 00:24:52
She's pretty skinny.
416
00:24:52 --> 00:24:57
417
00:24:57 --> 00:24:59
And another move in the James
Bond thing, which is an
418
00:24:59 --> 00:25:05
interesting thing in its own
right, which is that they still
419
00:25:05 --> 00:25:09
have to end up together by the
end of the movie, but they're
420
00:25:09 --> 00:25:14
getting a lot crankier about
the whole business, right.
421
00:25:14 --> 00:25:15
It's like they get
into this movie.
422
00:25:15 --> 00:25:18
They realize that by the end of
the movie, I've got to, you
423
00:25:18 --> 00:25:21
know be in one of those silly
scenes with whoever's playing
424
00:25:21 --> 00:25:25
Bond this week, but
he's a jerk really.
425
00:25:25 --> 00:25:27
But anyway, that's
a separate issue.
426
00:25:27 --> 00:25:31
Anyway they've been getting
skinnier and skinnier.
427
00:25:31 --> 00:25:35
Barbie has been skinny forever,
but gets blamed -- is held up
428
00:25:35 --> 00:25:39
literally as an icon for
this problem, you know.
429
00:25:39 --> 00:25:41
Women do not look like Barbie.
430
00:25:41 --> 00:25:47
If you scale Barbie up to
human size, there are serious
431
00:25:47 --> 00:25:52
biomechanical problems
that ensue, apparently.
432
00:25:52 --> 00:25:55
Somebody wrote a marvelous --
there's a great engineering
433
00:25:55 --> 00:25:59
piece on that somewhere that
I saw once upon a time.
434
00:25:59 --> 00:26:02
There are cantilevering
problems and all sorts of very
435
00:26:02 --> 00:26:06
bad problems with Barbie
if you scale her up.
436
00:26:06 --> 00:26:10
But the notion is that the
ideal of what is beautiful
437
00:26:10 --> 00:26:12
has been getting
skinnier and skinnier.
438
00:26:12 --> 00:26:19
At the same time, there has
been this surge in both
439
00:26:19 --> 00:26:24
the availability and the
diversity of food available.
440
00:26:24 --> 00:26:31
So you're expected to be skinny
while plunked down at this
441
00:26:31 --> 00:26:35
spectacular all you
can eat buffet.
442
00:26:35 --> 00:26:37
And that's, you know, you can
imagine that there are a
443
00:26:37 --> 00:26:39
certain amount of
problems there.
444
00:26:39 --> 00:26:44
There are specific populations,
and these are unsurprising
445
00:26:44 --> 00:26:47
specific populations, where
you see higher than average
446
00:26:47 --> 00:26:52
rates of eating disorders.
447
00:26:52 --> 00:26:58
So for instance, gymnasts,
eating disorders are
448
00:26:58 --> 00:27:00
overrepresented in
that population.
449
00:27:00 --> 00:27:06
If you're looking for male
eating disorder patients, a
450
00:27:06 --> 00:27:13
great place to look is in
the wrestling population.
451
00:27:13 --> 00:27:14
Why is that?
452
00:27:14 --> 00:27:17
Well, if you're wrestling in a
weight class and you have to be
453
00:27:17 --> 00:27:20
exactly this weight,
particularly since there's a
454
00:27:20 --> 00:27:25
pressure to wrestle in the
lightest weight class you can
455
00:27:25 --> 00:27:28
sort of get away with, there's
going to be a lot of pressure
456
00:27:28 --> 00:27:33
of the sort that's similar to
this pressure that you might
457
00:27:33 --> 00:27:38
imagine being applied by an
ideal of female beauty
458
00:27:38 --> 00:27:41
that's very skinny.
459
00:27:41 --> 00:27:43
So there are these pressures
-- yes, yes, yes?
460
00:27:43 --> 00:27:46
AUDIENCE: In wrestling they
also have [UNINTELLIGIBLE]
461
00:27:46 --> 00:27:50
they measure you a set
number of hours before
462
00:27:50 --> 00:27:51
the actual match.
463
00:27:51 --> 00:27:53
PROFESSOR: Yes.
464
00:27:53 --> 00:27:56
There are all sorts of reasons
why this is not inclined to
465
00:27:56 --> 00:28:02
produce wholesome eating
behavior as I understand it.
466
00:28:02 --> 00:28:04
My own personal
wrestling career --
467
00:28:04 --> 00:28:07
[LAUGHTER]
468
00:28:07 --> 00:28:11
Why are they all laughing?
469
00:28:11 --> 00:28:14
You know, it's only mildly --
well, I suppose maybe it's
470
00:28:14 --> 00:28:17
completely hilarious.
471
00:28:17 --> 00:28:18
It was clear that I
wasn't going to wrestle
472
00:28:18 --> 00:28:19
heavyweight, right.
473
00:28:19 --> 00:28:23
But, you know, the world is
full of these little tough
474
00:28:23 --> 00:28:26
guys as opposed to just
merely little guys.
475
00:28:26 --> 00:28:29
[LAUGHTER]
476
00:28:29 --> 00:28:38
Kristin, that letter I was
writing for you -- it's really
477
00:28:38 --> 00:28:40
bad when the people in your lab
are the ones who are
478
00:28:40 --> 00:28:43
becoming hysterical.
479
00:28:43 --> 00:28:45
Anyway, I might as
well complete this
480
00:28:45 --> 00:28:46
embarrassing story.
481
00:28:46 --> 00:28:50
482
00:28:50 --> 00:28:54
High school wrestling,
the gym teachers were
483
00:28:54 --> 00:28:56
always weird people.
484
00:28:56 --> 00:29:00
And so high school wrestling
you had to wrestle by
485
00:29:00 --> 00:29:01
weight class, right.
486
00:29:01 --> 00:29:02
That made sense.
487
00:29:02 --> 00:29:06
But our guy thought it
was like a circle.
488
00:29:06 --> 00:29:09
So you wrestled the guy
next to you in weight.
489
00:29:09 --> 00:29:13
Well, if you were the lightest
guy, it's going to be a hoot.
490
00:29:13 --> 00:29:17
Let's get him to wrestle
the heaviest guy.
491
00:29:17 --> 00:29:20
Which was actually OK because
the heaviest guy was just
492
00:29:20 --> 00:29:25
about as athletically
talented as I was.
493
00:29:25 --> 00:29:27
The major danger was that he
would fall on me, right,
494
00:29:27 --> 00:29:30
because then it was just
going to be all over.
495
00:29:30 --> 00:29:35
So I'm -- athletics was
not my strong suit.
496
00:29:35 --> 00:29:36
So there was no danger that
I was going to do him
497
00:29:36 --> 00:29:39
any serious damage.
498
00:29:39 --> 00:29:42
And there was no serious danger
that, as long as he didn't fall
499
00:29:42 --> 00:29:44
on me, I was going to get hurt.
500
00:29:44 --> 00:29:48
So I figured out a way to get
on his back and sort of rode
501
00:29:48 --> 00:29:54
him around for a while, and did
sort of manly things that
502
00:29:54 --> 00:29:56
looked like I might be trying
to flip him, but that wasn't
503
00:29:56 --> 00:29:59
ever going to happen.
504
00:29:59 --> 00:30:04
It was a great moment, made
greater of course by the
505
00:30:04 --> 00:30:10
fact that -- never mind.
506
00:30:10 --> 00:30:11
No, I should continue.
507
00:30:11 --> 00:30:18
This was also -- he was -- this
was full of -- this guy, deeply
508
00:30:18 --> 00:30:25
homophobic gym teacher who also
was fond of explaining that
509
00:30:25 --> 00:30:31
how hard you wrestled showed
whether you were a real guy.
510
00:30:31 --> 00:30:36
And anyway, it goes
downhill from there.
511
00:30:36 --> 00:30:40
So in any case, the
-- where were we?
512
00:30:40 --> 00:30:41
Oh yes.
513
00:30:41 --> 00:30:45
This explains why my wrestling
career did not produce any
514
00:30:45 --> 00:30:46
eating disorders in my case.
515
00:30:46 --> 00:30:52
So there are these societal or
specific cultural factors that
516
00:30:52 --> 00:30:56
might be pushing one towards
these sort of disorders.
517
00:30:56 --> 00:31:00
And then there's the question
of whether or not there's
518
00:31:00 --> 00:31:02
a biological factor there.
519
00:31:02 --> 00:31:08
Is there some sort of a genetic
predisposition towards this?
520
00:31:08 --> 00:31:13
The sorts of things that people
point to are data, for
521
00:31:13 --> 00:31:19
instance, that there are family
histories of depression, more
522
00:31:19 --> 00:31:25
depression showing up in the
families of eating disorder
523
00:31:25 --> 00:31:27
patients than in the
general population.
524
00:31:27 --> 00:31:29
There's also more depression
in eating disorder
525
00:31:29 --> 00:31:31
patients themselves.
526
00:31:31 --> 00:31:38
But as I've said, that's hard
to disentangle from the effects
527
00:31:38 --> 00:31:45
of starvation, that that
itself produces problems.
528
00:31:45 --> 00:31:53
In any case, well actually
there is one thing that is
529
00:31:53 --> 00:31:58
potentially a biological
underpinning.
530
00:31:58 --> 00:32:03
Has nothing to do with the
brain at all, but is simply
531
00:32:03 --> 00:32:11
-- in diet land, these are
known as set point issues.
532
00:32:11 --> 00:32:18
There's a notion that people
come with some sort of weight
533
00:32:18 --> 00:32:21
that is sort of the weight
that they are set for.
534
00:32:21 --> 00:32:25
The little thermostat in the
hypothalamus is to say, you
535
00:32:25 --> 00:32:27
know, you're going to be
180 pounds or whatever.
536
00:32:27 --> 00:32:31
You can push this around, but
this is where we want to be.
537
00:32:31 --> 00:32:34
It's related to the fact that
there are certainly genetic
538
00:32:34 --> 00:32:38
factors that are making you
one body shape versus
539
00:32:38 --> 00:32:39
another body shape.
540
00:32:39 --> 00:32:44
And if you are one shape and
you're feeling strongly
541
00:32:44 --> 00:32:47
pressured to be another shape
that is not the shape that you
542
00:32:47 --> 00:32:50
were sort of built to be,
that's considered to possibly
543
00:32:50 --> 00:32:56
be a biological factor pushing
people towards eating disorder.
544
00:32:56 --> 00:33:01
That's not like the sort of
factors we're thinking about as
545
00:33:01 --> 00:33:04
a genetic predisposition to
something like schizophrenia.
546
00:33:04 --> 00:33:07
That's really an interaction
of body type with these
547
00:33:07 --> 00:33:10
sort of cultural pressures.
548
00:33:10 --> 00:33:16
All right, so you've got
characteristics of family,
549
00:33:16 --> 00:33:19
patient, the culture as a
whole, possibly biological
550
00:33:19 --> 00:33:20
underpinnings.
551
00:33:20 --> 00:33:26
How might all of this
contribute to producing
552
00:33:26 --> 00:33:28
an actual disorder?
553
00:33:28 --> 00:33:33
One way to think about this is
to think about it as a trap
554
00:33:33 --> 00:33:37
that some subset of
girls fall into.
555
00:33:37 --> 00:33:38
Not consciously.
556
00:33:38 --> 00:33:41
Nobody wakes up in the morning
and says, "Gee, I think I'll
557
00:33:41 --> 00:33:43
have an eating disorder."
558
00:33:43 --> 00:33:48
But the unconscious process
might run something
559
00:33:48 --> 00:33:50
like the following.
560
00:33:50 --> 00:33:52
You hit puberty.
561
00:33:52 --> 00:33:54
So, all right, so you've been
this sort of perfectionist
562
00:33:54 --> 00:33:59
good girl all along.
563
00:33:59 --> 00:34:06
You hit puberty and sort of a
time that stretches or strains
564
00:34:06 --> 00:34:07
perfection altogether.
565
00:34:07 --> 00:34:10
566
00:34:10 --> 00:34:15
Being perfect requires a
certain amount of self-control,
567
00:34:15 --> 00:34:19
and you may recall the sort of
wash of hormones that
568
00:34:19 --> 00:34:22
accompanies the onset of
puberty is not particularly
569
00:34:22 --> 00:34:25
good for self-control.
570
00:34:25 --> 00:34:29
So the sense of control is
not what it used to be.
571
00:34:29 --> 00:34:32
Your body is changing in ways
that you don't control.
572
00:34:32 --> 00:34:36
And you're in this family where
the set of ways that you can
573
00:34:36 --> 00:34:39
act out is very limited.
574
00:34:39 --> 00:34:47
There are lots of ways to act
out in adolescence, but you're
575
00:34:47 --> 00:34:51
in a family where most of them
are sort of not sanctioned.
576
00:34:51 --> 00:34:57
So one way to sort of re-exert
a sense of control, a very
577
00:34:57 --> 00:35:00
culturally endorsed one, is
well, let's go on
578
00:35:00 --> 00:35:02
a diet, right.
579
00:35:02 --> 00:35:06
The percentage of women in this
country on diets at any time is
580
00:35:06 --> 00:35:11
huge and that goes down
to school-girl age.
581
00:35:11 --> 00:35:18
And if you ask -- you
go and talk to middle
582
00:35:18 --> 00:35:24
school boys about diet.
583
00:35:24 --> 00:35:26
Ehh.
584
00:35:26 --> 00:35:28
They sort of grunt at
you or something.
585
00:35:28 --> 00:35:31
You go and talk to middle
school girls about diet and
586
00:35:31 --> 00:35:32
they can talk your ear off.
587
00:35:32 --> 00:35:34
Whether or not they're
on some sort of a diet,
588
00:35:34 --> 00:35:36
they know all about it.
589
00:35:36 --> 00:35:39
This and the that.
590
00:35:39 --> 00:35:39
It's there.
591
00:35:39 --> 00:35:43
In fact, you might go on
a diet endorsed by mom.
592
00:35:43 --> 00:35:45
Mom might say, you're
looking a little chunky.
593
00:35:45 --> 00:35:47
And, you know, we
can do it together.
594
00:35:47 --> 00:35:49
It's a mother daughter
kind of thing.
595
00:35:49 --> 00:35:52
Well, you know, particularly
since, you know, we're really
596
00:35:52 --> 00:35:54
enmeshed here anyway.
597
00:35:54 --> 00:35:55
All right.
598
00:35:55 --> 00:36:00
Well, you can sort of imagine
that a perfectionist on a diet,
599
00:36:00 --> 00:36:06
under the right circumstances,
could be a recipe for
600
00:36:06 --> 00:36:09
disaster, you know.
601
00:36:09 --> 00:36:13
It's sort of like
MIT and sleeping.
602
00:36:13 --> 00:36:17
People out there say, all
right, I need to do a
603
00:36:17 --> 00:36:19
little extra work so I'll
stay up an extra hour.
604
00:36:19 --> 00:36:23
MIT student says, I
don't need to sleep.
605
00:36:23 --> 00:36:25
You know.
606
00:36:25 --> 00:36:28
Most people out in the world
say, diet, oh, OK, we'll cut
607
00:36:28 --> 00:36:34
out the double dip, you know,
double-stuffed Oreos and, OK,
608
00:36:34 --> 00:36:36
we won't deep fry the pizza.
609
00:36:36 --> 00:36:41
610
00:36:41 --> 00:36:46
And this hypothetical
perfectionist says, water.
611
00:36:46 --> 00:36:48
Lettuce and water.
612
00:36:48 --> 00:36:49
That'll work.
613
00:36:49 --> 00:36:53
So anyway, you can imagine that
the diet could -- that what
614
00:36:53 --> 00:36:57
happens when this is spiraling
downwards, this diet can
615
00:36:57 --> 00:37:00
become increasingly severe.
616
00:37:00 --> 00:37:05
And at some point it
becomes a real issue.
617
00:37:05 --> 00:37:08
It becomes a source of conflict
in the family because it
618
00:37:08 --> 00:37:11
becomes clearly unhealthy.
619
00:37:11 --> 00:37:13
It's clear to anybody except
for the patient that
620
00:37:13 --> 00:37:14
this is unhealthy.
621
00:37:14 --> 00:37:19
But at that point, if you
regard this as some sort of an
622
00:37:19 --> 00:37:23
assertion of autonomy, this is
the last place where this girl
623
00:37:23 --> 00:37:25
has managed to find a place
where she can carve out
624
00:37:25 --> 00:37:28
someplace where she
is in control.
625
00:37:28 --> 00:37:32
Now the family is saying,
you can't do that either.
626
00:37:32 --> 00:37:34
And she draws the line.
627
00:37:34 --> 00:37:36
This is where I'm going
to make my stand.
628
00:37:36 --> 00:37:39
629
00:37:39 --> 00:37:47
And it can become a clearly
pathological state.
630
00:37:47 --> 00:37:51
People in full blast anorexia
deny that they are hungry in
631
00:37:51 --> 00:37:56
spite of being strongly
malnourished.
632
00:37:56 --> 00:38:00
The rituals around eating, the
rituals that get built up
633
00:38:00 --> 00:38:02
around eating can be extremely
elaborate and extremely
634
00:38:02 --> 00:38:04
time consuming.
635
00:38:04 --> 00:38:10
Along with, for instance, very
vigorous exercise regimens that
636
00:38:10 --> 00:38:12
-- basically it takes
over your life.
637
00:38:12 --> 00:38:16
Plus being starved not only
tends to make you depressed,
638
00:38:16 --> 00:38:20
but it also can make
you delusional in
639
00:38:20 --> 00:38:22
a variety of ways.
640
00:38:22 --> 00:38:24
So it's clearly not
a good place to be.
641
00:38:24 --> 00:38:26
So that's the sense in
which it's a disaster.
642
00:38:26 --> 00:38:31
It's also in a sense -- the
sense in which it's a success,
643
00:38:31 --> 00:38:34
this notion of it being a
successful disaster, the sense
644
00:38:34 --> 00:38:37
in which it's a success is if
you regard this as an issue
645
00:38:37 --> 00:38:47
about control, in some sense,
the patient, the daughter, has
646
00:38:47 --> 00:38:50
managed to take control
over the family.
647
00:38:50 --> 00:38:54
That wasn't her goal, but
there's nothing like a
648
00:38:54 --> 00:38:57
life-threatening condition
to galvanize the
649
00:38:57 --> 00:39:00
attention of a family.
650
00:39:00 --> 00:39:06
And here in this clearly
pathological way, the daughter
651
00:39:06 --> 00:39:10
has become the center of
the family's attention.
652
00:39:10 --> 00:39:15
This quiet, never caused any
trouble, you know, bury the
653
00:39:15 --> 00:39:19
problems elsewhere daughter
has now successfully
654
00:39:19 --> 00:39:21
taken over the family.
655
00:39:21 --> 00:39:25
The problem with that success
is it's clearly desperately
656
00:39:25 --> 00:39:27
maladaptive and
potentially dangerous.
657
00:39:27 --> 00:39:31
Well, what do you do?
658
00:39:31 --> 00:39:41
As you can imagine, virtually
every major psychotherapeutic
659
00:39:41 --> 00:39:44
regimen has been tried
in some fashion.
660
00:39:44 --> 00:39:50
The punchline, the bottom line,
is that my understanding of
661
00:39:50 --> 00:39:55
best practice is that nothing
by itself works terribly well
662
00:39:55 --> 00:39:59
and that what you do is
some of everything.
663
00:39:59 --> 00:40:01
Now, what is everything?
664
00:40:01 --> 00:40:07
Well, one bit of everything
is you've got to get
665
00:40:07 --> 00:40:09
the patient to eat.
666
00:40:09 --> 00:40:13
Often by the time you've got an
eating disorder patient who has
667
00:40:13 --> 00:40:19
reached the point of being in
medical care, this is a
668
00:40:19 --> 00:40:21
potentially life-threatening
situation.
669
00:40:21 --> 00:40:24
And the patients often
get hospitalized.
670
00:40:24 --> 00:40:27
Under hospital settings, one of
the things that works really
671
00:40:27 --> 00:40:29
well, and one of the things
that was once upon a time
672
00:40:29 --> 00:40:37
touted as a magic silver bullet
cure, comes straight out of
673
00:40:37 --> 00:40:41
Skinner boxes and behaviorist
theory, you know,
674
00:40:41 --> 00:40:42
learning theory.
675
00:40:42 --> 00:40:47
And that is to set up the
ward, well basically as
676
00:40:47 --> 00:40:49
a giant Skinner box.
677
00:40:49 --> 00:40:51
OK, there's stuff
you want, right?
678
00:40:51 --> 00:40:54
You want to be able to
call your friends?
679
00:40:54 --> 00:40:54
Good.
680
00:40:54 --> 00:40:56
Here's what you've got to eat.
681
00:40:56 --> 00:41:00
You want to be
able to watch TV?
682
00:41:00 --> 00:41:01
Good.
683
00:41:01 --> 00:41:04
Here's the weight standard
you have to reach.
684
00:41:04 --> 00:41:09
And so you set up a clearly
defined set of rewards in
685
00:41:09 --> 00:41:11
response for eating behaviors.
686
00:41:11 --> 00:41:15
And it works very
nicely in many cases.
687
00:41:15 --> 00:41:19
You can get people back up to
weights that are appropriate
688
00:41:19 --> 00:41:23
for, you know, age and height.
689
00:41:23 --> 00:41:24
Works just fine.
690
00:41:24 --> 00:41:26
Why isn't it a magic bullet?
691
00:41:26 --> 00:41:29
Well, what happens when you
go out of the hospital?
692
00:41:29 --> 00:41:33
You go out of the hospital,
you're back in the environment
693
00:41:33 --> 00:41:37
that produced the
disorder in some sense.
694
00:41:37 --> 00:41:39
And it tends to fall apart.
695
00:41:39 --> 00:41:44
The problem was that relapse
rates were very great.
696
00:41:44 --> 00:41:48
697
00:41:48 --> 00:41:52
So one of the things you're
going to want to do is not just
698
00:41:52 --> 00:41:54
treat -- people aren't pigeons.
699
00:41:54 --> 00:41:57
You don't want to treat
them just as pigeons.
700
00:41:57 --> 00:42:01
You can train your pigeon to do
whatever with a nice schedule
701
00:42:01 --> 00:42:03
of reinforcement and probably
that doesn't work too well when
702
00:42:03 --> 00:42:06
you release the pigeon
into the wild either.
703
00:42:06 --> 00:42:09
With a human, it's
nice to talk to them.
704
00:42:09 --> 00:42:13
So psychotherapeutic approaches
have been -- you know, various
705
00:42:13 --> 00:42:15
forms of talk therapy
have been tried.
706
00:42:15 --> 00:42:19
Freudian therapy centered
around the idea that -- the
707
00:42:19 --> 00:42:24
core issue here was a fear of
growing up in the sort of
708
00:42:24 --> 00:42:31
typical Freudian tendency to
sexualize everything under the
709
00:42:31 --> 00:42:37
sun, this gets described as a
fear of pregnancy, that, well,
710
00:42:37 --> 00:42:42
you know, if you manage to
suppress menstrual cycles and
711
00:42:42 --> 00:42:45
things like that, you're not
going to become pregnant.
712
00:42:45 --> 00:42:49
And by starving yourself,
your body will be more like
713
00:42:49 --> 00:42:50
that of a little girl.
714
00:42:50 --> 00:42:56
It's a little like the sort of
metaphoric senses of trying --
715
00:42:56 --> 00:42:59
of Snow White's evil stepmother
trying to keep Snow
716
00:42:59 --> 00:43:00
White as a little girl.
717
00:43:00 --> 00:43:04
But anyway the Freudian notion
was that there is a certain
718
00:43:04 --> 00:43:09
terror about getting older, you
know, growing up, that the
719
00:43:09 --> 00:43:12
patients are dealing with.
720
00:43:12 --> 00:43:14
Just talking to him about it
didn't turn out to be a huge
721
00:43:14 --> 00:43:21
success, in part because
patients who are that
722
00:43:21 --> 00:43:25
undernourished are a little
like schizophrenic patients.
723
00:43:25 --> 00:43:28
They're not good candidates for
psychoanalysis or for much
724
00:43:28 --> 00:43:30
other in the way of
talking therapy.
725
00:43:30 --> 00:43:32
Delusional people are
not great at insight.
726
00:43:32 --> 00:43:36
727
00:43:36 --> 00:43:42
So combining some sort of
conversation, some sort of
728
00:43:42 --> 00:43:46
therapeutic conversation, with
something like the behavioral
729
00:43:46 --> 00:43:49
modification technique,
that helps.
730
00:43:49 --> 00:43:53
There is evidence that
pharmacology helps.
731
00:43:53 --> 00:43:58
There is an obsessive quality
to the thought processes
732
00:43:58 --> 00:44:01
of anorexic patients.
733
00:44:01 --> 00:44:03
They're deeply
obsessed with food.
734
00:44:03 --> 00:44:06
In fact, you get these
fascinating case histories
735
00:44:06 --> 00:44:11
where the anorexic is doing all
the cooking for the family.
736
00:44:11 --> 00:44:12
She loves to cook
for everybody.
737
00:44:12 --> 00:44:14
She just doesn't
eat any of this.
738
00:44:14 --> 00:44:17
You know, absolutely obsessed
with food, swearing they're
739
00:44:17 --> 00:44:23
not hungry and engaging in
elaborate rituals
740
00:44:23 --> 00:44:24
around eating.
741
00:44:24 --> 00:44:29
You know, that's an obsessive
kind of behavior that turns out
742
00:44:29 --> 00:44:35
to be broken up by Prozac and
similar drugs quite well.
743
00:44:35 --> 00:44:39
So one thing to do is to feed
them an antidepressant like
744
00:44:39 --> 00:44:42
Prozac, in part because they
may be depressed and in part
745
00:44:42 --> 00:44:44
because it acts against
the obsessive thoughts.
746
00:44:44 --> 00:44:48
Just feeding them an
antidepressant by itself
747
00:44:48 --> 00:44:50
has no great track record.
748
00:44:50 --> 00:44:53
But, all right, let's combine a
little antidepressant
749
00:44:53 --> 00:44:55
medication with a little
behavior modification, a little
750
00:44:55 --> 00:44:59
talk therapy, this is all
working -- this all might
751
00:44:59 --> 00:45:03
have some meat to it.
752
00:45:03 --> 00:45:10
One of the things that seems to
be an interesting part of
753
00:45:10 --> 00:45:14
treatment regimens in eating
disorders, more so perhaps than
754
00:45:14 --> 00:45:18
elsewhere, is it's often useful
in anorexia particularly to
755
00:45:18 --> 00:45:20
talk with the family also.
756
00:45:20 --> 00:45:26
Because that family, they're
actually -- there are
757
00:45:26 --> 00:45:33
clinicians who argue that
anorexia is a disorder of the
758
00:45:33 --> 00:45:36
family where it just happens
to be that the girl is the
759
00:45:36 --> 00:45:42
designated patient, that the
family as a system is sick and
760
00:45:42 --> 00:45:45
that the daughter is
showing the symptom.
761
00:45:45 --> 00:45:51
And that if you want to have
this work out, that what you
762
00:45:51 --> 00:45:56
need to do is to treat the
family and get the family out
763
00:45:56 --> 00:46:00
of each other's faces a little
more, and more willing to
764
00:46:00 --> 00:46:03
express feelings to each other
perhaps and things
765
00:46:03 --> 00:46:05
of that sort.
766
00:46:05 --> 00:46:12
The prognosis is a little
reminiscent of Anna O., if you
767
00:46:12 --> 00:46:17
remember that story from the
history of Freud's development.
768
00:46:17 --> 00:46:19
Anna O.
769
00:46:19 --> 00:46:23
had symptoms that Freud and
Breuer could treat, but
770
00:46:23 --> 00:46:26
when those were treated,
something new popped up.
771
00:46:26 --> 00:46:29
There's a flavor of that when
you read about case histories
772
00:46:29 --> 00:46:35
of anorexia, that you can
-- most patients recover.
773
00:46:35 --> 00:46:38
They become non-anorexic.
774
00:46:38 --> 00:46:42
But the population sees more
depression going forward
775
00:46:42 --> 00:46:44
than a typical population.
776
00:46:44 --> 00:46:49
The population sees more other
eating disorders than a typical
777
00:46:49 --> 00:46:52
population, as if there's
something that was
778
00:46:52 --> 00:46:55
not dealt with.
779
00:46:55 --> 00:47:01
And exactly what that is, we
clearly don't really know, but
780
00:47:01 --> 00:47:04
that anorexia was a particular
crisis and that there are
781
00:47:04 --> 00:47:07
issues that may need to
be dealt with on a
782
00:47:07 --> 00:47:09
long-term basis.
783
00:47:09 --> 00:47:15
Now, one of the disorders that
you can, sort of, progress to,
784
00:47:15 --> 00:47:19
if you like, not infrequently,
or you can manage to generate
785
00:47:19 --> 00:47:23
it all by itself, is bulimia,
or more technically,
786
00:47:23 --> 00:47:24
bulimia nervosa.
787
00:47:24 --> 00:47:27
Though anorexia nervosa gets
called anorexia nervosa,
788
00:47:27 --> 00:47:31
bulimia often just
gets called bulimia.
789
00:47:31 --> 00:47:33
Oh, did we just switch?
790
00:47:33 --> 00:47:34
Oh, look at that.
791
00:47:34 --> 00:47:37
It's so much fun to watch
everybody go [SWISHING SOUND].
792
00:47:37 --> 00:47:41
It's glad to know you're
following along.
793
00:47:41 --> 00:47:44
So bulimia is -- one of the
reasons -- a follow-on disorder
794
00:47:44 --> 00:47:47
-- well, I don't know
if it's a reason.
795
00:47:47 --> 00:47:49
It's not surprising it's
a follow-on disorder.
796
00:47:49 --> 00:47:53
It's characteristic of
an older population.
797
00:47:53 --> 00:48:02
Typical onset in college age or
twenties and a different kind
798
00:48:02 --> 00:48:06
of, sort of a different story.
799
00:48:06 --> 00:48:10
So one important characteristic
is these are patients typically
800
00:48:10 --> 00:48:12
who are outside of the
family situation.
801
00:48:12 --> 00:48:13
They're not embedded
in their family.
802
00:48:13 --> 00:48:15
They've gone off to college
or they've gone off to work
803
00:48:15 --> 00:48:18
or something of that sort.
804
00:48:18 --> 00:48:22
A bit insecure -- let's go back
to this we're not necessarily
805
00:48:22 --> 00:48:24
talking about you thing.
806
00:48:24 --> 00:48:25
A bit insecure -- right.
807
00:48:25 --> 00:48:26
Who isn't?
808
00:48:26 --> 00:48:29
The ones who aren't a little
bit insecure are the people,
809
00:48:29 --> 00:48:33
you know, near and dear to
us who are insufferable.
810
00:48:33 --> 00:48:35
So a little bit
insecure, maybe.
811
00:48:35 --> 00:48:37
Maybe a bit more
insecure than usual.
812
00:48:37 --> 00:48:39
A bit impulsive.
813
00:48:39 --> 00:48:40
What's impulsive?
814
00:48:40 --> 00:48:43
When you get the family
history, sorry, the patient's
815
00:48:43 --> 00:48:49
history, you get anecdotes
about, you know, dumb
816
00:48:49 --> 00:48:50
impulsive things.
817
00:48:50 --> 00:48:53
Oh, on a whim I
shoplifted once.
818
00:48:53 --> 00:48:59
It's not like I'm a
chronic shoplifter.
819
00:48:59 --> 00:49:03
You get sort of dumb single
incident kind of things
820
00:49:03 --> 00:49:06
in these reports.
821
00:49:06 --> 00:49:13
And self-esteem not great, and
wants to fit in, which of
822
00:49:13 --> 00:49:15
course qualifies for most of
us also, at least the
823
00:49:15 --> 00:49:17
wants to fit in part.
824
00:49:17 --> 00:49:23
So the dilemma faced by this
woman now living independently
825
00:49:23 --> 00:49:28
is that the fitting in
piece involves socializing.
826
00:49:28 --> 00:49:33
And the socializing involves a
lot of eating and drinking.
827
00:49:33 --> 00:49:39
Fitting in also involves,
rather literally, fitting into
828
00:49:39 --> 00:49:43
those jeans or whatever that
were designed for some
829
00:49:43 --> 00:49:47
half-starved model in the
fashion magazines somewhere.
830
00:49:47 --> 00:49:53
And so you've got this conflict
between food and thinness
831
00:49:53 --> 00:49:57
made quite concrete.
832
00:49:57 --> 00:50:02
And these are our patients who,
in a sense, stumble on a trick.
833
00:50:02 --> 00:50:07
And the trick is that if you
eat and then you get rid of the
834
00:50:07 --> 00:50:12
food, those calories don't
end up on your hips, right?
835
00:50:12 --> 00:50:18
So if you eat and then take a
laxative or throw up, then you
836
00:50:18 --> 00:50:20
don't get the calories, right?
837
00:50:20 --> 00:50:23
Now, that's a solution,
but it's not a really
838
00:50:23 --> 00:50:24
great solution.
839
00:50:24 --> 00:50:26
It's not a great solution
for any number of reasons.
840
00:50:26 --> 00:50:29
One of them is that,
interestingly, it
841
00:50:29 --> 00:50:32
feels shameful.
842
00:50:32 --> 00:50:34
That's interesting because you
could go onto a whole thing
843
00:50:34 --> 00:50:39
about why -- no -- I suppose
no is probably too strong.
844
00:50:39 --> 00:50:45
A typical bulimic is not going
to have a buddy bulimic who,
845
00:50:45 --> 00:50:48
you know, let's go off and go
to this party and eat and
846
00:50:48 --> 00:50:50
go throw up together.
847
00:50:50 --> 00:50:53
I mean, it even sounds
weird -- oh, by the way.
848
00:50:53 --> 00:50:58
This is not unknown culturally,
though I realized talking to my
849
00:50:58 --> 00:51:00
concourse class this morning
that it's apparently much
850
00:51:00 --> 00:51:03
less known than I thought.
851
00:51:03 --> 00:51:08
Because my eight year old can
tell you all about this.
852
00:51:08 --> 00:51:15
But in Roman culture, sort of
high Roman Empire culture,
853
00:51:15 --> 00:51:18
there were, I don't know how
widespread this was, but
854
00:51:18 --> 00:51:25
certainly in the orgy class,
there was a custom of having
855
00:51:25 --> 00:51:29
these, you know, very elaborate
parties where you'd eat and
856
00:51:29 --> 00:51:32
eat and eat and then you
couldn't eat anymore.
857
00:51:32 --> 00:51:34
But you wanted to keep eating
so you went to the next room,
858
00:51:34 --> 00:51:38
you threw up, and you came
back and you ate some more.
859
00:51:38 --> 00:51:45
And so there are even villas
with rooms that are designated
860
00:51:45 --> 00:51:48
as the vomitorium.
861
00:51:48 --> 00:51:52
And so how many people
knew about this?
862
00:51:52 --> 00:51:53
All right, so it is a minority.
863
00:51:53 --> 00:51:57
It's absolutely fascinating to
a certain round of eight
864
00:51:57 --> 00:52:03
year-old boys, who think this
is, you know, really
865
00:52:03 --> 00:52:04
very interesting.
866
00:52:04 --> 00:52:07
Not something they want to
try, thank you, but you know,
867
00:52:07 --> 00:52:09
that's really -- well, they
like other gross stuff.
868
00:52:09 --> 00:52:13
Anyway, the problem is that
first of all it's something
869
00:52:13 --> 00:52:15
that feels shameful and needs
to be done in private.
870
00:52:15 --> 00:52:22
871
00:52:22 --> 00:52:25
It's clearly sort of
an odd solution.
872
00:52:25 --> 00:52:28
So maybe you try a more
mainstream solution.
873
00:52:28 --> 00:52:30
Let's go on a diet.
874
00:52:30 --> 00:52:32
And maybe it becomes a
fairly severe diet.
875
00:52:32 --> 00:52:38
But unlike anorexics, who deny
their hunger and really don't
876
00:52:38 --> 00:52:42
seem to feel that hunger,
bulimics feel hungry.
877
00:52:42 --> 00:52:43
They feel really hungry.
878
00:52:43 --> 00:52:45
And so the diet doesn't work.
879
00:52:45 --> 00:52:48
And what you end up with
is that the diet breaks
880
00:52:48 --> 00:52:49
down at some point.
881
00:52:49 --> 00:52:52
You go off the diet, perhaps
in some spectacular
882
00:52:52 --> 00:52:53
bingy kind of a way.
883
00:52:53 --> 00:52:57
Well, that feels lousy too.
884
00:52:57 --> 00:53:00
And so, well, you figured
out this trick once.
885
00:53:00 --> 00:53:05
You go and purge again
in some fashion.
886
00:53:05 --> 00:53:07
And that gives you some
transient release from
887
00:53:07 --> 00:53:08
the shame of having
broken the diet.
888
00:53:08 --> 00:53:12
But again, the purging
thing isn't great either.
889
00:53:12 --> 00:53:16
But this can become -- and in
full-blast bulimia it becomes
890
00:53:16 --> 00:53:19
a very ritualized behavior
in its own right.
891
00:53:19 --> 00:53:28
Actually, somebody was telling
me that some bulimics plan
892
00:53:28 --> 00:53:33
things very carefully so that
they eat the nutritive foods
893
00:53:33 --> 00:53:41
first in a sort of a binging
session and then finish up with
894
00:53:41 --> 00:53:45
the half gallon of ice cream
and the jar of mayonnaise.
895
00:53:45 --> 00:53:47
I mean, the things you read
people -- seriously, the things
896
00:53:47 --> 00:53:50
you read the people eating
on bulimic binges are
897
00:53:50 --> 00:53:52
really quite amazing.
898
00:53:52 --> 00:53:55
Imagining sitting down and
eating a thing of mayonnaise
899
00:53:55 --> 00:53:59
is just very odd, but this is
the sort of thing that gets,
900
00:53:59 --> 00:54:02
that apparently -- anyway.
901
00:54:02 --> 00:54:08
But you stagger it in such a
way so that you get at least
902
00:54:08 --> 00:54:12
enough of the nutrients that
you need before you go and
903
00:54:12 --> 00:54:15
purge that you're not
starving yourself.
904
00:54:15 --> 00:54:18
And bulimia, unlike
anorexia, can be a very
905
00:54:18 --> 00:54:19
long-term disorder.
906
00:54:19 --> 00:54:27
People can maintain body weight
for a long time doing this.
907
00:54:27 --> 00:54:32
It's clearly not adaptive.
908
00:54:32 --> 00:54:37
I mean, it's a success in,
again, in a limited sense.
909
00:54:37 --> 00:54:42
Let's you eat and lets you
maintain this skinny weight.
910
00:54:42 --> 00:54:44
But in many other ways
it's a disaster.
911
00:54:44 --> 00:54:48
First of all, repeated purging
is very bad for, you know, do a
912
00:54:48 --> 00:54:53
variety of bits of permanent
damage to you physiologically.
913
00:54:53 --> 00:54:56
It carries with it its
own risk of mortality.
914
00:54:56 --> 00:54:59
Again, typically from heart
attack from getting
915
00:54:59 --> 00:55:04
electrolytes sufficiently
imbalanced to stop the heart.
916
00:55:04 --> 00:55:10
And it does really bad
things to that hunger
917
00:55:10 --> 00:55:15
drive circuitry in places
like your hypothalamus.
918
00:55:15 --> 00:55:20
Because what happens
is the body is smart.
919
00:55:20 --> 00:55:29
It says, we ate a half
gallon of ice cream and
920
00:55:29 --> 00:55:31
a thing of mayonnaise.
921
00:55:31 --> 00:55:37
And we got this much caloric
bounce out of that.
922
00:55:37 --> 00:55:39
You know, that's odd.
923
00:55:39 --> 00:55:41
I don't know what the
problem here is, but I
924
00:55:41 --> 00:55:43
know how to adapt to that.
925
00:55:43 --> 00:55:47
If it is the case that huge
amounts of food are not
926
00:55:47 --> 00:55:52
providing me with the calories
I need, me up in the
927
00:55:52 --> 00:55:55
hypothalamus here, well, the
answer is something's
928
00:55:55 --> 00:55:56
wrong in the gut.
929
00:55:56 --> 00:55:58
But the answer is I
better eat more.
930
00:55:58 --> 00:56:03
I've got to make this sucker
hungrier, ramp up the hunger.
931
00:56:03 --> 00:56:07
Bulimia, the word comes from
to have an appetite like
932
00:56:07 --> 00:56:09
an ox, like a bull.
933
00:56:09 --> 00:56:13
Because what happens is that
the body learns that food isn't
934
00:56:13 --> 00:56:18
doing it for you anymore and
you just keep eating it.
935
00:56:18 --> 00:56:19
It's a vicious cycle.
936
00:56:19 --> 00:56:21
You've got to eat
more and more.
937
00:56:21 --> 00:56:25
Well, this other -- it's two
chunks of your brain fighting.
938
00:56:25 --> 00:56:28
This hard-wired chunk of
hunger drive is saying,
939
00:56:28 --> 00:56:30
need this many calories.
940
00:56:30 --> 00:56:33
If it takes, you know, this
many truck loads of food to
941
00:56:33 --> 00:56:35
get it, well, go out and
eat that truck load.
942
00:56:35 --> 00:56:37
And you've got this other chunk
of the brain saying, we're
943
00:56:37 --> 00:56:40
getting in those jeans, man,
so go and throw up again.
944
00:56:40 --> 00:56:42
And these two are fighting
with each other in a way
945
00:56:42 --> 00:56:46
that's clearly at this
point maladaptive.
946
00:56:46 --> 00:56:52
Now, we have this -- the
regular population away from
947
00:56:52 --> 00:56:55
the eating disorder population
runs into the same problem, by
948
00:56:55 --> 00:56:58
the way, with diet foods.
949
00:56:58 --> 00:57:03
Diet foods don't give you the
caloric punch of regular foods.
950
00:57:03 --> 00:57:05
That's the whole idea.
951
00:57:05 --> 00:57:11
So these little chunks
of the brain say, hey,
952
00:57:11 --> 00:57:14
eat twice as many.
953
00:57:14 --> 00:57:14
See the label?
954
00:57:14 --> 00:57:17
It says half as much fat.
955
00:57:17 --> 00:57:22
Brain says, eat twice as many.
956
00:57:22 --> 00:57:26
And the other thing it says is,
you know, what do you like?
957
00:57:26 --> 00:57:29
Well, you're built to
like -- brain says, we
958
00:57:29 --> 00:57:31
like double-stuffed
Cheerios -- Cheerios.
959
00:57:31 --> 00:57:33
Oreos.
960
00:57:33 --> 00:57:34
There's probably double-stuffed
Cheerios now too.
961
00:57:34 --> 00:57:37
Anyway, we like double-stuffed
Oreos because they've got lots
962
00:57:37 --> 00:57:42
of calories and this little
piece of my brain is still, you
963
00:57:42 --> 00:57:45
know, foraging around
on the savannah.
964
00:57:45 --> 00:57:48
And when I found double-stuffed
Oreos on the savannah, man, I
965
00:57:48 --> 00:57:51
could live for a week off
of one of those suckers.
966
00:57:51 --> 00:57:52
It's great stuff.
967
00:57:52 --> 00:57:56
Now, you're eating the low-fat
reduced everything version
968
00:57:56 --> 00:58:01
of this, and the brain is
saying, lousy stuff, man.
969
00:58:01 --> 00:58:04
You're eating bark
and twigs here.
970
00:58:04 --> 00:58:07
So it doesn't taste
good to me no more.
971
00:58:07 --> 00:58:11
Even though it tasted perfectly
-- this is one of the reasons
972
00:58:11 --> 00:58:15
why diet foods cycle through
the supermarket much more
973
00:58:15 --> 00:58:22
rapidly than high-fat foods,
which is that any diet food
974
00:58:22 --> 00:58:26
tends to have a fall off in its
appeal to the population
975
00:58:26 --> 00:58:30
fairly rapidly.
976
00:58:30 --> 00:58:33
The Oreos stay there forever
because people love them.
977
00:58:33 --> 00:58:39
The reduced fat all-twig Oreos
have to be replaced next week
978
00:58:39 --> 00:58:44
by the, you know, low carb,
reduced fat, high cardboard
979
00:58:44 --> 00:58:47
Oreos or something, in a
brand-new package so that
980
00:58:47 --> 00:58:48
you'll go out and try it.
981
00:58:48 --> 00:58:51
Because, well, you know, those
low fat ones, they were OK for
982
00:58:51 --> 00:58:54
a while, but my hypothalamus is
now telling me they
983
00:58:54 --> 00:58:56
weren't that good.
984
00:58:56 --> 00:58:58
So you have to keep churning
the product line in
985
00:58:58 --> 00:59:00
order to keep you happy.
986
00:59:00 --> 00:59:03
Treatment turns out to
be much the same story
987
00:59:03 --> 00:59:08
as with anorexia.
988
00:59:08 --> 00:59:11
Nothing by itself works.
989
00:59:11 --> 00:59:12
There are a couple
of big differences.
990
00:59:12 --> 00:59:15
One is, as I said before, you
can go for a very long time
991
00:59:15 --> 00:59:19
without seeking treatment
because it's not as acute
992
00:59:19 --> 00:59:22
a disorder as full
blast anorexia is.
993
00:59:22 --> 00:59:24
It's not good for you, but
you can maintain this.
994
00:59:24 --> 00:59:27
Plus it's a very private
disorder and so you can tend to
995
00:59:27 --> 00:59:30
maintain it all by your little
lonesome for a fairly
996
00:59:30 --> 00:59:32
long period of time.
997
00:59:32 --> 00:59:34
The other thing is that it
no longer turns out to be
998
00:59:34 --> 00:59:37
desperately interesting to talk
to the family about this.
999
00:59:37 --> 00:59:38
You're outside the family.
1000
00:59:38 --> 00:59:41
But in place of that what turns
out to be an interesting
1001
00:59:41 --> 00:59:44
component of treatment
is group therapy.
1002
00:59:44 --> 00:59:48
This has been a very isolating
disorder, and when you finally
1003
00:59:48 --> 00:59:50
come to treatment, you
say to yourself in some
1004
00:59:50 --> 00:59:52
fashion, I am so weird.
1005
00:59:52 --> 00:59:55
There's nobody else
like me in the world.
1006
00:59:55 --> 00:59:58
And that doesn't help you.
1007
00:59:58 --> 01:00:01
That's just depressing and
off-putting in its own right.
1008
01:00:01 --> 01:00:04
If you're with a group of other
people with a similar disorder,
1009
01:00:04 --> 01:00:06
you're saying, look, hey,
it turns out there are
1010
01:00:06 --> 01:00:07
other people like this.
1011
01:00:07 --> 01:00:09
We'll work through
this thing together.
1012
01:00:09 --> 01:00:13
And that turns out to have
some therapeutic value.
1013
01:00:13 --> 01:00:17
Again like anorexia, people
tend to get over this and then
1014
01:00:17 --> 01:00:22
tend to have, to need to sort
of be vigilant about food
1015
01:00:22 --> 01:00:26
issues and vigilant about other
such issues ongoing past that
1016
01:00:26 --> 01:00:31
as if there were some
underlying issue that hasn't
1017
01:00:31 --> 01:00:34
quite been addressed.
1018
01:00:34 --> 01:00:38
So, well, I think what I will
do unless there's some -- oh,
1019
01:00:38 --> 01:00:40
no, I got to all the various
words on the handout.
1020
01:00:40 --> 01:00:41
Look at that.
1021
01:00:41 --> 01:00:45
Let's take a break, and then
what I'll do is at least set up
1022
01:00:45 --> 01:00:50
the problem of coercive sexual
behavior and we'll
1023
01:00:50 --> 01:00:53
go on from there.
1024
01:00:53 --> 01:01:12
[PRIVATE CONVERSATION]
1025
01:01:12 --> 01:01:17
AUDIENCE: Is there any good
evolutionary reason that girls
1026
01:01:17 --> 01:01:21
get anorexia or is it just
that we idealize the girls --
1027
01:01:21 --> 01:01:27
PROFESSOR: The mainline
argument I think is the
1028
01:01:27 --> 01:01:32
pressures are exerted on girls
much more than boys, that if
1029
01:01:32 --> 01:01:39
the ideal guy had -- there are
sort of muscle building-ish
1030
01:01:39 --> 01:01:41
disorders in guys that
might be comparable.
1031
01:01:41 --> 01:01:42
AUDIENCE: Is it
1032
01:01:42 --> 01:01:42
formally diagnosed?
1033
01:01:42 --> 01:01:45
PROFESSOR: Is it
formally diagnosed?
1034
01:01:45 --> 01:01:46
I don't know.
1035
01:01:46 --> 01:01:46
[INTERPOSING VOICES]
1036
01:01:46 --> 01:01:49
AUDIENCE: [INAUDIBLE]
1037
01:01:49 --> 01:01:54
PROFESSOR: I would be amazed if
it wasn't because everything is
1038
01:01:54 --> 01:01:57
formally diagnosed somewhere.
1039
01:01:57 --> 01:02:02
But, you know, what really
shows up there, I think, is
1040
01:02:02 --> 01:02:05
substance abuse, right?
1041
01:02:05 --> 01:02:09
In this culture it's much less
that you get somebody who's
1042
01:02:09 --> 01:02:11
pathologically working out in
the gym, though I'm
1043
01:02:11 --> 01:02:12
sure that happens.
1044
01:02:12 --> 01:02:16
They go and pop enough steroids
to get themselves into trouble.
1045
01:02:16 --> 01:02:16
AUDIENCE: What about
1046
01:02:16 --> 01:02:22
the cases where people make
themselves throw up but not
1047
01:02:22 --> 01:02:25
particularly related to food?
1048
01:02:25 --> 01:02:27
PROFESSOR: Well, OK, there's a
whole -- and I don't actually
1049
01:02:27 --> 01:02:31
know much about the whole set
of self-harming disorders.
1050
01:02:31 --> 01:02:34
Actually I should probably
sometime teach myself
1051
01:02:34 --> 01:02:34
something about it.
1052
01:02:34 --> 01:02:43
Because there's another
pathology that is new, I think.
1053
01:02:43 --> 01:02:47
Or if it's not new it was
deeply hidden before,
1054
01:02:47 --> 01:02:49
the notion of people
cutting themselves
1055
01:02:49 --> 01:02:51
and things like that.
1056
01:02:51 --> 01:02:54
So it may be that there's a --
I don't know anything about it,
1057
01:02:54 --> 01:02:56
but there may well be a make
yourself throw up in the
1058
01:02:56 --> 01:02:59
self-harming kind of category.
1059
01:02:59 --> 01:03:04
1060
01:03:04 --> 01:03:05
AUDIENCE: Have you
ever heard of
1061
01:03:05 --> 01:03:06
the anorexia
1062
01:03:06 --> 01:03:06
Web sites?
1063
01:03:06 --> 01:03:07
Like not the --
1064
01:03:07 --> 01:03:07
PROFESSOR: The anorexia --
1065
01:03:07 --> 01:03:09
AUDIENCE: Like, Web sites --
1066
01:03:09 --> 01:03:11
PROFESSOR: Oh, yes,
yes, yes, yes.
1067
01:03:11 --> 01:03:13
I read an article about it at
one point, where people are
1068
01:03:13 --> 01:03:16
busy encouraging each other
in their eating disorders.
1069
01:03:16 --> 01:03:18
Not wholesome, I wouldn't say.
1070
01:03:18 --> 01:03:19
AUDIENCE: Yes, clearly.
1071
01:03:19 --> 01:03:20
But did they change
the [INAUDIBLE]
1072
01:03:20 --> 01:03:22
at all, or the way anorexia --
1073
01:03:22 --> 01:03:23
PROFESSOR: I don't know.
1074
01:03:23 --> 01:03:24
I don't know.
1075
01:03:24 --> 01:03:26
And I don't know if it's
widespread enough to be -- I
1076
01:03:26 --> 01:03:32
mean, I've just seen a couple
of, you know, I think sort of
1077
01:03:32 --> 01:03:34
popular press things about it.
1078
01:03:34 --> 01:03:37
I just don't know how
widespread that is.
1079
01:03:37 --> 01:03:38
I know who to ask at MIT.
1080
01:03:38 --> 01:03:40
There are a couple of people
who are good experts
1081
01:03:40 --> 01:03:43
on that at MIT.
1082
01:03:43 --> 01:03:52
Anyway, the dangers of
relatively complete handouts or
1083
01:03:52 --> 01:03:56
of comparatively complete
handouts is that if I don't
1084
01:03:56 --> 01:04:01
then hit all the lines on the
handout, there's a danger that
1085
01:04:01 --> 01:04:04
somebody's going to want to
know what I meant by magic
1086
01:04:04 --> 01:04:07
cures for imperfections
and the superwoman myth.
1087
01:04:07 --> 01:04:13
So let's jump back to societal
pressures pushing people
1088
01:04:13 --> 01:04:14
towards anorexia.
1089
01:04:14 --> 01:04:17
1090
01:04:17 --> 01:04:22
The magical cure thing is the
notion that we're a culture
1091
01:04:22 --> 01:04:25
that firmly believes that you
should be able to cure your
1092
01:04:25 --> 01:04:29
problems right now and without
too much real hard work.
1093
01:04:29 --> 01:04:39
So that if you are not sexy
enough, here is the mouthwash,
1094
01:04:39 --> 01:04:45
the clothes, and the six
amazing acts that you can
1095
01:04:45 --> 01:04:49
perform in the privacy of your
own room that will
1096
01:04:49 --> 01:04:50
do it all for you.
1097
01:04:50 --> 01:04:54
And you can read these at the
supermarket checkout, right?
1098
01:04:54 --> 01:04:55
One of my favorite -- I
mean, you get stuck at the
1099
01:04:55 --> 01:05:00
supermarket checkout -- I love
bouncing down just the
1100
01:05:00 --> 01:05:05
headlines of what are described
as the women's magazines, Cosmo
1101
01:05:05 --> 01:05:07
being the best of these.
1102
01:05:07 --> 01:05:10
Because Cosmo is always willing
to make you completely
1103
01:05:10 --> 01:05:11
sexy by next month.
1104
01:05:11 --> 01:05:13
And amazingly they need to do
it all again the next month.
1105
01:05:13 --> 01:05:16
But, you know.
1106
01:05:16 --> 01:05:23
This move will drive your man
wild, once a month on the --
1107
01:05:23 --> 01:05:25
anyway, it's great stuff.
1108
01:05:25 --> 01:05:27
At least I suppose
it's great stuff.
1109
01:05:27 --> 01:05:28
I don't get to read
the journal much.
1110
01:05:28 --> 01:05:33
It's not one of the technical
journals in my field.
1111
01:05:33 --> 01:05:35
All right, so there's
the magic cure piece.
1112
01:05:35 --> 01:05:41
And then the superwoman myth,
which many of the superwomen
1113
01:05:41 --> 01:05:48
here may relate to, is a -- I
can't remember who coined the
1114
01:05:48 --> 01:05:52
term -- but it's the idea of
the woman, or the guy for
1115
01:05:52 --> 01:05:55
that matter, who can
do it all, right.
1116
01:05:55 --> 01:05:59
She's got the high-powered
career based on her
1117
01:05:59 --> 01:06:01
great MIT degree.
1118
01:06:01 --> 01:06:08
And she also is the mother of
fifteen and making it to all
1119
01:06:08 --> 01:06:11
the school plays and making the
food and of course knitting the
1120
01:06:11 --> 01:06:14
clothes by hand and
stuff like that.
1121
01:06:14 --> 01:06:18
There's typically not a similar
superman myth because even in
1122
01:06:18 --> 01:06:22
these more egalitarian days, it
still remains the case that the
1123
01:06:22 --> 01:06:26
burden of child rearing falls
more heavily on the female than
1124
01:06:26 --> 01:06:33
on the male typically
across this culture.
1125
01:06:33 --> 01:06:38
So if anybody is going to be
massively stressed out by
1126
01:06:38 --> 01:06:41
trying to balance the home
and career thing, it's more
1127
01:06:41 --> 01:06:42
likely to be the woman.
1128
01:06:42 --> 01:06:47
At least, that's the argument
that's being made here.
1129
01:06:47 --> 01:06:54
All right, let me jump then
to this other topic of
1130
01:06:54 --> 01:06:57
coercive sexual behavior.
1131
01:06:57 --> 01:07:04
And let me advocate that you
should take advantage of your
1132
01:07:04 --> 01:07:08
time in Cambridge sometime to
go to the American Repertory
1133
01:07:08 --> 01:07:12
Theater just off the
Harvard campus, across the
1134
01:07:12 --> 01:07:15
street from Radcliffe.
1135
01:07:15 --> 01:07:18
Because I think -- my
recollection is -- actually I
1136
01:07:18 --> 01:07:19
haven't checked lately because
I haven't been a student
1137
01:07:19 --> 01:07:20
for a long time.
1138
01:07:20 --> 01:07:23
Students used to get
in amazingly cheaply.
1139
01:07:23 --> 01:07:25
And so you should do this.
1140
01:07:25 --> 01:07:29
They put on a range plays from
modern to classic, but almost
1141
01:07:29 --> 01:07:34
always with some kind of out
there attitude about it.
1142
01:07:34 --> 01:07:43
So I remember this great
production of a Handel opera,
1143
01:07:43 --> 01:07:50
which they had decided to set
-- act one was set in a trailer
1144
01:07:50 --> 01:07:56
park in a Florida swamp, and
act two was set on Mars,
1145
01:07:56 --> 01:07:59
neither of which I believe were
described as the settings
1146
01:07:59 --> 01:08:01
in the original libretto.
1147
01:08:01 --> 01:08:03
Somebody -- that kind of thing.
1148
01:08:03 --> 01:08:08
Anyway, some years ago, I saw a
production of Shakespeare's
1149
01:08:08 --> 01:08:10
Midsummer Night's Dream there.
1150
01:08:10 --> 01:08:13
And at the beginning of the
play, what they had done was
1151
01:08:13 --> 01:08:17
they staged a practice fight.
1152
01:08:17 --> 01:08:25
It was clear that these were
two knights practicing rather
1153
01:08:25 --> 01:08:28
than fighting in an actual
battle, sparring
1154
01:08:28 --> 01:08:29
with each other.
1155
01:08:29 --> 01:08:32
And they're whacking away at --
the lights come up and they're
1156
01:08:32 --> 01:08:33
whacking away at each other.
1157
01:08:33 --> 01:08:38
And finally one of them
flattens the other and pulls
1158
01:08:38 --> 01:08:44
a sword and it's at the neck
of the guy on the ground.
1159
01:08:44 --> 01:08:50
And at that point, the lines
you hear are, "Hippolyta, I
1160
01:08:50 --> 01:08:53
wooed thee with my sword; and
won thy love doing
1161
01:08:53 --> 01:08:54
thee injuries.
1162
01:08:54 --> 01:08:56
But I will wed thee in
another key, with pomp, with
1163
01:08:56 --> 01:09:00
triumph, and with reveling."
1164
01:09:00 --> 01:09:00
What the A.R.T.
1165
01:09:00 --> 01:09:07
had done was at the moment that
the fight was over, the guy on
1166
01:09:07 --> 01:09:10
the floor is reciting
those lines.
1167
01:09:10 --> 01:09:15
And the other person
takes off her helmet.
1168
01:09:15 --> 01:09:18
And of course to make it
dramatic, her big hair fluffs
1169
01:09:18 --> 01:09:20
out all over the place.
1170
01:09:20 --> 01:09:23
1171
01:09:23 --> 01:09:28
The beginning of Midsummer
Night's Dream is the set up --
1172
01:09:28 --> 01:09:30
the set up is that there's
going to be a wedding between
1173
01:09:30 --> 01:09:33
Theseus, Duke of Athens, and
Hippolyta, the Queen of the
1174
01:09:33 --> 01:09:38
Amazons, who he has conquered
and is now going to marry.
1175
01:09:38 --> 01:09:43
But the notion of "I wooed thee
with my sword and won thy love
1176
01:09:43 --> 01:09:49
doing thee injuries" does not
sit well in, at least not in a
1177
01:09:49 --> 01:09:52
Cambridge academic
kind of setting.
1178
01:09:52 --> 01:09:55
And so the A.R.T.
1179
01:09:55 --> 01:09:59
played this against type,
right, with Theseus on the
1180
01:09:59 --> 01:10:03
floor saying, "I wooed you with
my -- oh, get that away from my
1181
01:10:03 --> 01:10:12
neck." But it's an interesting,
curious thought that you might
1182
01:10:12 --> 01:10:16
woo somebody with your
sword and win their love
1183
01:10:16 --> 01:10:17
doing them injuries.
1184
01:10:17 --> 01:10:20
1185
01:10:20 --> 01:10:25
I suspect there aren't very
many women present who would
1186
01:10:25 --> 01:10:27
subscribe to the notion that
that would be a marvelous form
1187
01:10:27 --> 01:10:32
of courtship, and maybe not
even an awful lot of guys.
1188
01:10:32 --> 01:10:35
1189
01:10:35 --> 01:10:43
But forms of relations that
become coercive are by
1190
01:10:43 --> 01:10:45
no means unheard of.
1191
01:10:45 --> 01:10:48
And the place we typically
end up hearing about them is
1192
01:10:48 --> 01:10:50
when they end up in court.
1193
01:10:50 --> 01:10:51
How do they end up in court?
1194
01:10:51 --> 01:10:53
Well, let me tell
you a court case.
1195
01:10:53 --> 01:10:57
This happened about
ten years ago now.
1196
01:10:57 --> 01:11:02
This is a court case where a
woman is suing a collection
1197
01:11:02 --> 01:11:04
of -- she's suing them?
1198
01:11:04 --> 01:11:07
No, I think this was
actually a rape case
1199
01:11:07 --> 01:11:09
in the criminal court.
1200
01:11:09 --> 01:11:13
They're charged with rape
and she's the plaintiff.
1201
01:11:13 --> 01:11:15
What happened?
1202
01:11:15 --> 01:11:19
Well, considerable disagreement
about what happened when
1203
01:11:19 --> 01:11:20
you end up in court.
1204
01:11:20 --> 01:11:24
But what basically seems to
have happened is that the woman
1205
01:11:24 --> 01:11:29
and one of the guys met at, I
think it was rifle practice,
1206
01:11:29 --> 01:11:32
some sort of athletic practice.
1207
01:11:32 --> 01:11:38
He invited her back
to his residence.
1208
01:11:38 --> 01:11:44
Alcohol followed and she ended
up having some variety of
1209
01:11:44 --> 01:11:53
sexual relations with like six
different guys and subsequently
1210
01:11:53 --> 01:11:55
charged them with rape.
1211
01:11:55 --> 01:12:00
She argued that she had been
passing in and out of
1212
01:12:00 --> 01:12:03
consciousness and that they
had basically abused her.
1213
01:12:03 --> 01:12:06
They argued that this
was consensual.
1214
01:12:06 --> 01:12:10
I think what happened in this
particular case, by the way, is
1215
01:12:10 --> 01:12:14
that there was no conviction
for rape but several of
1216
01:12:14 --> 01:12:18
the guys ended up being
expelled from school.
1217
01:12:18 --> 01:12:20
There are lots of things
one could talk about here.
1218
01:12:20 --> 01:12:25
I'm not in the business for a
psych course of giving a sort
1219
01:12:25 --> 01:12:29
of an RO week lecture about,
you know, good behavior
1220
01:12:29 --> 01:12:31
or something like that.
1221
01:12:31 --> 01:12:35
But the interesting issue --
well, there are lots of
1222
01:12:35 --> 01:12:37
interesting psych issues.
1223
01:12:37 --> 01:12:39
The interesting psych issue
that I want to focus on is the
1224
01:12:39 --> 01:12:43
question of how this could come
to pass given that probably
1225
01:12:43 --> 01:12:45
nobody wanted it
to come to pass.
1226
01:12:45 --> 01:12:51
It is extremely unlikely that
she went to whatever it was,
1227
01:12:51 --> 01:12:56
rifle practice, saying, oh gee,
I think I'll go home with this
1228
01:12:56 --> 01:12:59
guy, get smashed out of my
mind, and have sex with
1229
01:12:59 --> 01:13:01
all of his roommates.
1230
01:13:01 --> 01:13:03
Doesn't seem likely.
1231
01:13:03 --> 01:13:08
Nor does it seem very likely
that he said to himself, oh I
1232
01:13:08 --> 01:13:11
think I'll take this friend of
mine home and we'll all have
1233
01:13:11 --> 01:13:15
too much to drink and she'll
have sex with everybody
1234
01:13:15 --> 01:13:16
under the sun.
1235
01:13:16 --> 01:13:22
So it's pretty clear that
this is not what anybody
1236
01:13:22 --> 01:13:25
particularly had in mind.
1237
01:13:25 --> 01:13:26
How does it come to pass?
1238
01:13:26 --> 01:13:27
Oh, look at that.
1239
01:13:27 --> 01:13:30
I must have said that
on the handout.
1240
01:13:30 --> 01:13:33
What am I talking about next?
1241
01:13:33 --> 01:13:37
Lots of questions, most of
which we cannot address.
1242
01:13:37 --> 01:13:39
All right.
1243
01:13:39 --> 01:13:42
So let's address some of
the ones we can address.
1244
01:13:42 --> 01:13:45
As it says there, very
gender-specific problem.
1245
01:13:45 --> 01:13:52
There are certainly instances
of sexual coercion going
1246
01:13:52 --> 01:13:56
the other -- female- on-
male sexual coercion.
1247
01:13:56 --> 01:13:58
And within homosexual
relationships there are
1248
01:13:58 --> 01:14:02
certainly instances
of sexual coercion.
1249
01:14:02 --> 01:14:07
But the great bulk of
these cases are male-
1250
01:14:07 --> 01:14:11
on- female coercion.
1251
01:14:11 --> 01:14:18
In fact, the female- on- male
coercion incidents is vastly
1252
01:14:18 --> 01:14:23
higher in the erotic
literature than it is in
1253
01:14:23 --> 01:14:25
reality apparently.
1254
01:14:25 --> 01:14:27
1255
01:14:27 --> 01:14:33
Well, remember the example from
earlier on about imagine that
1256
01:14:33 --> 01:14:38
you're on the subway and some
member of the sex that you find
1257
01:14:38 --> 01:14:42
attractive begins to touch you
surreptitiously on a
1258
01:14:42 --> 01:14:43
crowded subway car.
1259
01:14:43 --> 01:14:45
Is this a good thing
or a bad thing?
1260
01:14:45 --> 01:14:49
Women uniformly say this is
not good, and guys, well, not
1261
01:14:49 --> 01:14:53
quite uniformly, say mmm, OK.
1262
01:14:53 --> 01:14:56
1263
01:14:56 --> 01:15:03
You can get similar data
with coercive relations.
1264
01:15:03 --> 01:15:11
You know, the leather-bound
woman who shows up and says,
1265
01:15:11 --> 01:15:18
"You're having sex with me
right now" is a fantasy figure.
1266
01:15:18 --> 01:15:20
The leather-bound guy who comes
up to a woman and says, "You're
1267
01:15:20 --> 01:15:22
having sex with me right now"
is not typically a
1268
01:15:22 --> 01:15:25
fantasy figure.
1269
01:15:25 --> 01:15:30
So there's this odd
asymmetry there.
1270
01:15:30 --> 01:15:41
So there are lots of ways
to understand how this
1271
01:15:41 --> 01:15:45
could come to pass.
1272
01:15:45 --> 01:15:48
One of the reasons, as I said
earlier, for making this an end
1273
01:15:48 --> 01:15:52
of the term kind of topic is it
does sort of neatly
1274
01:15:52 --> 01:15:56
recapitulate an awful lot of
the themes about causality that
1275
01:15:56 --> 01:16:01
have shown up in the
course of the term.
1276
01:16:01 --> 01:16:04
And then what I'll probably,
oh, very clearly do next time
1277
01:16:04 --> 01:16:07
is weave a story that
combines many different
1278
01:16:07 --> 01:16:08
threads into one.
1279
01:16:08 --> 01:16:13
Let me just say a word about
incidence today, and then
1280
01:16:13 --> 01:16:17
we'll go on to etiology
when we pick up next time.
1281
01:16:17 --> 01:16:19
How common is this
as a problem?
1282
01:16:19 --> 01:16:23
Well, you've got a real problem
here, which I have mentioned
1283
01:16:23 --> 01:16:28
before, which is the data on
sexual behavior are lousy.
1284
01:16:28 --> 01:16:31
Because people don't --
well, first of all we don't
1285
01:16:31 --> 01:16:32
collect that much of it.
1286
01:16:32 --> 01:16:34
And second of all people lie.
1287
01:16:34 --> 01:16:39
Recall that if you ask males
how many sexual partners have
1288
01:16:39 --> 01:16:43
you had and you ask females how
many sexual partners have you
1289
01:16:43 --> 01:16:47
had, you discover that
there's a third sex
1290
01:16:47 --> 01:16:50
out there somewhere.
1291
01:16:50 --> 01:16:52
Because the math
doesn't add up.
1292
01:16:52 --> 01:16:57
You see that too in -- well,
maybe you see that in the data
1293
01:16:57 --> 01:17:01
on -- that's gotten basically
from survey data --
1294
01:17:01 --> 01:17:02
on coercive sex.
1295
01:17:02 --> 01:17:12
If you ask females, "have you
ever been coerced into sexual
1296
01:17:12 --> 01:17:15
intercourse?", in at least
one study the answer is
1297
01:17:15 --> 01:17:18
15% of women say yes.
1298
01:17:18 --> 01:17:23
If you ask men, "have you
coerced anybody into having
1299
01:17:23 --> 01:17:27
sexual intercourse?",
only 7% of males say yes.
1300
01:17:27 --> 01:17:30
Now there are a number of
possible explanations, like
1301
01:17:30 --> 01:17:34
serial coercers or things of
that sort, but you can see that
1302
01:17:34 --> 01:17:38
there may be reporting issues
that are difficult there.
1303
01:17:38 --> 01:17:43
One last point on this, on the
incidence point, if you ask
1304
01:17:43 --> 01:17:48
have you ever -- 25% of women
in one study back from the mid
1305
01:17:48 --> 01:17:54
'80s reported intercourse
because quote "they were
1306
01:17:54 --> 01:17:57
overwhelmed by a man's
continual arguments and
1307
01:17:57 --> 01:18:00
pressure." That's an
interesting statistic
1308
01:18:00 --> 01:18:01
in a couple of ways.
1309
01:18:01 --> 01:18:03
First of all it's interesting
because it's quite high.
1310
01:18:03 --> 01:18:07
Second of all it's interesting
because it points out the
1311
01:18:07 --> 01:18:10
very distinct status of
sexual relationships.
1312
01:18:10 --> 01:18:16
If I am coerced into buying a
used car by the man's continual
1313
01:18:16 --> 01:18:21
arguments and pressure,
that's too bad, right.
1314
01:18:21 --> 01:18:26
If I decide that I'm going
to strangle -- who am
1315
01:18:26 --> 01:18:27
I going to strangle?
1316
01:18:27 --> 01:18:28
Oh, I don't know.
1317
01:18:28 --> 01:18:29
I won't strangle
anybody particular.
1318
01:18:29 --> 01:18:31
Oh, maybe I'll strangle
Kristin because she was
1319
01:18:31 --> 01:18:33
laughing at me earlier.
1320
01:18:33 --> 01:18:37
I'll strangle Kristin because
I was pressured by Anna's
1321
01:18:37 --> 01:18:41
continuous verbal demands or
something like that to do this.
1322
01:18:41 --> 01:18:44
You know, I can make the case
that it was her demands that
1323
01:18:44 --> 01:18:48
made me do this, but I'm
still going to jail.
1324
01:18:48 --> 01:18:52
It doesn't explain
away my behavior.
1325
01:18:52 --> 01:18:54
Sexual relations are
interestingly different from
1326
01:18:54 --> 01:18:58
other relations in that way.
1327
01:18:58 --> 01:19:02
And, OK, we'll pick up on,
at our last meeting, on how
1328
01:19:02 --> 01:19:04
this all comes to pass.
1329
01:19:04 --> 01:19:05